MEDICARE: MRS. GLENDA ALISE 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	376G00000X	Nursing Home Administrator	375268750696	OH

General Provider Information

NPI Number	:	1689832420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GLENDA ALISE JOHNSON

Provider Business Mailing Address
First Line	:	13514 KELSO AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110
Country	:	US
Telephone Number	:	216-925-6559
Fax Number	:

Provider Business Practice Location Address
First Line	:	13514 KELSO AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110
Country	:	US
Telephone Number	:	216-925-6559
Fax Number	:

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

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	05/11/2026

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