Healthcare Provider Details

I. General information

NPI: 1407396922
Provider Name (Legal Business Name): HEATHER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 FULTON DR NW
CANTON OH
44718-2819
US

IV. Provider business mailing address

4143 FULTON DR NW
CANTON OH
44718-2819
US

V. Phone/Fax

Practice location:
  • Phone: 330-244-8888
  • Fax:
Mailing address:
  • Phone: 330-244-8888
  • Fax: 330-244-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020497
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: