Provider Demographics
NPI:1376693101
Name:JOHNSON, ROCHELLE LORAINE (NP)
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:LORAINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ROCHELLE
Other - Middle Name:LORAINE
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-969-6200
Mailing Address - Fax:260-969-6201
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-969-6200
Practice Address - Fax:260-969-6201
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001549A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ23690Medicare UPIN
IN048010KMedicare ID - Type Unspecified