Provider Demographics
NPI:1275071391
Name:JOHNSON, MAKAYLA ROSE
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:ROSE
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 1:17001 N ANGLER CLUB RD
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:IN
Mailing Address - Zip Code:47342-9225
Mailing Address - Country:US
Mailing Address - Phone:765-702-7167
Mailing Address - Fax:
Practice Address - Street 1:17001 N ANGLER CLUB RD
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:IN
Practice Address - Zip Code:47342-9225
Practice Address - Country:US
Practice Address - Phone:765-702-7167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program