Provider Demographics
NPI:1073045746
Name:WREN, JOHNNIE JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNIE
Middle Name:JACQUELINE
Last Name:WREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MARGARET ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1893
Mailing Address - Country:US
Mailing Address - Phone:518-314-3939
Mailing Address - Fax:
Practice Address - Street 1:15 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:AU SABLE FORKS
Practice Address - State:NY
Practice Address - Zip Code:21912
Practice Address - Country:US
Practice Address - Phone:518-647-8164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06303951Medicaid