Provider Demographics
NPI:1235380742
Name:JOHNSON, LAURA L (FNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-223-2020
Mailing Address - Fax:574-223-5847
Practice Address - Street 1:1400 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-8931
Practice Address - Country:US
Practice Address - Phone:574-223-2020
Practice Address - Fax:574-223-5847
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002759A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918880Medicaid
IN151560K3Medicare PIN