Provider Demographics
NPI:1275204604
Name:JOHNSON, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
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 1:100 SILVERADO DR
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-5406
Mailing Address - Country:US
Mailing Address - Phone:608-417-8700
Mailing Address - Fax:608-417-8701
Practice Address - Street 1:100 SILVERADO DR
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-5406
Practice Address - Country:US
Practice Address - Phone:608-417-8700
Practice Address - Fax:608-417-8701
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI227175-30163W00000X
WI11477-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse