Provider Demographics
NPI:1053029140
Name:JOHNSON, EVELYN C
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:C
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 1:5306 OAKCREST CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-8027
Mailing Address - Country:US
Mailing Address - Phone:513-545-6783
Mailing Address - Fax:
Practice Address - Street 1:5306 OAKCREST CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-8027
Practice Address - Country:US
Practice Address - Phone:513-545-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1301906171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH72086326Medicaid