Provider Demographics
NPI:1033897426
Name:JOHNSON, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
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 1:37 DESERT DAWN LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-2910
Mailing Address - Country:US
Mailing Address - Phone:360-356-5619
Mailing Address - Fax:
Practice Address - Street 1:37 DESERT DAWN LN
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-2910
Practice Address - Country:US
Practice Address - Phone:360-356-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program