Provider Demographics
NPI:1043268758
Name:JOHNSON, NANCY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W. 69TH ST.
Mailing Address - Street 2:STE. 1500
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8171
Mailing Address - Country:US
Mailing Address - Phone:605-322-5700
Mailing Address - Fax:605-322-5704
Practice Address - Street 1:4400 W. 69TH ST.
Practice Address - Street 2:STE. 1500
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8171
Practice Address - Country:US
Practice Address - Phone:605-322-5700
Practice Address - Fax:605-322-5704
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01846103TC0700X
SD531103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO332725OtherHEALTHLINK
MO6151573OtherUNITED HEALTHCARE
MO498837301Medicaid
MO110056OtherBLUE SHIELD/BLUE CHOICE
MO223255236Medicare PIN
MO332725OtherHEALTHLINK
MO498837301Medicaid
MO680008636Medicare PIN