Provider Demographics
NPI:1427397769
Name:JOHNSON, REBECCA L (APN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-0865
Mailing Address - Country:US
Mailing Address - Phone:417-683-6790
Mailing Address - Fax:417-683-6770
Practice Address - Street 1:120 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-683-6790
Practice Address - Fax:417-683-6770
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR196066758Medicaid
AR57297Medicare PIN
AR196066758Medicaid