Basic Information
| Provider Information | |||||||||
| NPI: | 1679110209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | CLARISSA | ||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198681178 | ||||||||
| FaxNumber: | 4198681986 | ||||||||
| Practice Location | |||||||||
| Address1: | 6715 DORR ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198681178 | ||||||||
| FaxNumber: | 4198681989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2019 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN468266 | OH | N | Nursing Service Providers | Registered Nurse | 251S00000X | N | Agencies | Community/Behavioral Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0382248 | 05 | OH | MEDICAID |