Healthcare Provider Details

I. General information

NPI: 1124362223
Provider Name (Legal Business Name): LISA DANIELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 E 143RD ST
CLEVELAND OH
44110-1802
US

IV. Provider business mailing address

454 E 143RD ST
CLEVELAND OH
44110-1802
US

V. Phone/Fax

Practice location:
  • Phone: 216-224-2000
  • Fax:
Mailing address:
  • Phone: 216-224-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: