Provider Demographics
NPI:1669402053
Name:JOHNSTON, LAVONNE ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:ROSE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAVONNE
Other - Middle Name:ROSE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2112 HARRISBURG PIKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3500
Mailing Address - Fax:717-544-3501
Practice Address - Street 1:2112 HARRISBURG PIKE
Practice Address - Street 2:SUITE 202
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-544-3500
Practice Address - Fax:717-544-3501
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000735L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA000735LOtherLICENSE
PAMA000735LOtherLICENSE
MJ1430723OtherDEA
PA102568JW2Medicare PIN