Provider Demographics
NPI:1770212268
Name:JOHNSON, LIZETTE NADENE
Entity type:Individual
Prefix:
First Name:LIZETTE
Middle Name:NADENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 N WABASH RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-9066
Mailing Address - Country:US
Mailing Address - Phone:765-618-6933
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28117541A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management