MEDICARE: LISA JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	RR998267	OH

General Provider Information

NPI Number	:	1376315424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JOHNSON

Provider Business Mailing Address
First Line	:	14001 SCIOTO AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3738
Country	:	US
Telephone Number	:	216-421-4427
Fax Number	:

Provider Business Practice Location Address
First Line	:	14001 SCIOTO AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3738
Country	:	US
Telephone Number	:	216-421-4427
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	10/23/2023

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Directions to “ LISA JOHNSON ” Practice Location

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