Provider Demographics
NPI:1265497275
Name:JOHNSON, LAURA (LPN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 MCLAINE RD SE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9239
Mailing Address - Country:US
Mailing Address - Phone:580-226-4301
Mailing Address - Fax:
Practice Address - Street 1:1001 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1810
Practice Address - Country:US
Practice Address - Phone:580-223-3737
Practice Address - Fax:580-226-5679
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0037822164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKL0037822OtherLPN LICENSE #