Provider Demographics
NPI:1003401449
Name:JOHANSEN, REBECCA RAE (NP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 PLEASANT ST STE 308
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1409
Mailing Address - Country:US
Mailing Address - Phone:515-241-4325
Mailing Address - Fax:
Practice Address - Street 1:1215 PLEASANT ST STE 308
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1409
Practice Address - Country:US
Practice Address - Phone:515-241-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA157622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily