Provider Demographics
NPI:1417085705
Name:JOHNSON, MARY ALICE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY ALICE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY ALICE
Other - Middle Name:
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4266
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:920-498-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66618-30163W00000X
WI033282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43316600Medicaid
WI0006-07855Medicare ID - Type UnspecifiedPROVIDER NUMBER