Provider Demographics
NPI:1780495689
Name:JOHNSON, ANDRE WYDELL SR
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:WYDELL
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 HORTON ST # 43620
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1749
Mailing Address - Country:US
Mailing Address - Phone:419-557-1311
Mailing Address - Fax:
Practice Address - Street 1:2120 HORTON ST # 43620
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1749
Practice Address - Country:US
Practice Address - Phone:419-557-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN8012693747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant