Provider Demographics
NPI:1447752035
Name:LAURA L. JOHNSON, N.P., P.C.
Entity Type:Organization
Organization Name:LAURA L. JOHNSON, N.P., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:541-890-8826
Mailing Address - Street 1:1619 NW HAWTHORNE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6009
Mailing Address - Country:US
Mailing Address - Phone:541-916-8530
Mailing Address - Fax:541-916-8533
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6009
Practice Address - Country:US
Practice Address - Phone:541-916-8530
Practice Address - Fax:541-916-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050002NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616623Medicaid