Provider Demographics
NPI:1235164963
Name:JOHNSON, ELLEN A (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:A
Last Name:JOHNSON
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:PO BOX 300
Mailing Address - Street 2:4TH & WILLOW STREET
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:171-272-4451
Mailing Address - Fax:717-272-4532
Practice Address - Street 1:6 PERRI AVENUE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-3200
Practice Address - Country:US
Practice Address - Phone:717-949-6581
Practice Address - Fax:717-949-2070
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039460E207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001116065Medicaid
516908PUDMedicare ID - Type Unspecified
PA001116065Medicaid