Healthcare Provider Details

I. General information

NPI: 1639007859
Provider Name (Legal Business Name): NYDRA C JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 TRIANGLE VIEW DR
DAYTON OH
45414-5554
US

IV. Provider business mailing address

2755 TRIANGLE VIEW DR
DAYTON OH
45414-5554
US

V. Phone/Fax

Practice location:
  • Phone: 937-304-3582
  • Fax:
Mailing address:
  • Phone: 937-304-3582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: