Provider Demographics
NPI:1013216308
Name:JOHNSON, COLLEEN MARONEY (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARONEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MARONEY-RUTTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MAIL STATION 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:8600 75TH ST STE 101
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8200
Practice Address - Country:US
Practice Address - Phone:262-652-9430
Practice Address - Fax:262-652-9433
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60072-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1013216308Medicaid