Provider Demographics
NPI:1205285608
Name:JOHNSON, LESLIE (PN160084-M-IV)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PN160084-M-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 E 175TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2221
Mailing Address - Country:US
Mailing Address - Phone:216-905-5188
Mailing Address - Fax:
Practice Address - Street 1:4085 EAST 175 TH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128
Practice Address - Country:US
Practice Address - Phone:216-905-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.160084-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse