Provider Demographics
NPI:1124375787
Name:JOHNSON, PAULETTE LYNN
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 NORTH RD.
Mailing Address - Street 2:APT. 2
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446
Mailing Address - Country:US
Mailing Address - Phone:330-240-9443
Mailing Address - Fax:
Practice Address - Street 1:525 NORTH RD
Practice Address - Street 2:APT. 2
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2025
Practice Address - Country:US
Practice Address - Phone:330-240-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN384037163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2947539Medicaid