Provider Demographics
NPI:1164206728
Name:JOHNSON, RAE LYNN
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:LYNN
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 1:1610 HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6099
Mailing Address - Country:US
Mailing Address - Phone:501-831-3023
Mailing Address - Fax:
Practice Address - Street 1:411 LENTZ RD
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-3740
Practice Address - Country:US
Practice Address - Phone:501-354-1170
Practice Address - Fax:501-354-0095
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR29821163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse