Provider Demographics
NPI:1346832128
Name:JOHNSON, MARY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
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 1:83 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-9127
Mailing Address - Country:US
Mailing Address - Phone:719-367-0241
Mailing Address - Fax:
Practice Address - Street 1:3524 AIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4701
Practice Address - Country:US
Practice Address - Phone:719-524-6627
Practice Address - Fax:719-524-6621
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN0046296164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPN0046296OtherDORA COLORADO