Provider Demographics
NPI:1114014644
Name:FICKETT, JOHANNA ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ELLEN
Last Name:FICKETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-0036
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2457
Practice Address - Street 1:1270 KOT-NUM RD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2457
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME027695163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health