Provider Demographics
NPI: | 1043615560 |
---|---|
Name: | JOHNSON, JENNIFER DIANE (FNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | DIANE |
Last Name: | JOHNSON |
Suffix: | |
Gender: | F |
Credentials: | FNP |
Other - Prefix: | |
Other - First Name: | JENNIFER |
Other - Middle Name: | DIANE |
Other - Last Name: | PSOTA |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | FNP |
Mailing Address - Street 1: | 27431 N. LAKE DRIVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WATERFORD |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53185 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 608-358-8449 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 725 AMERICAN AVENUE |
Practice Address - Street 2: | |
Practice Address - City: | WAUKESHA |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53188 |
Practice Address - Country: | US |
Practice Address - Phone: | 212-928-8800 |
Practice Address - Fax: | 262-928-0648 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-10-27 |
Last Update Date: | 2023-07-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 171464-30 | 163W00000X |
WI | 6088-33 | 363L00000X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 163W00000X | Nursing Service Providers | Registered Nurse | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |