Provider Demographics
NPI:1457646812
Name:JOHNSON, WENDY D (PMHNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S CLEAR CREEK RD STE 216
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4198
Mailing Address - Country:US
Mailing Address - Phone:254-519-8803
Mailing Address - Fax:
Practice Address - Street 1:2301 S CLEAR CREEK RD STE 216
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4198
Practice Address - Country:US
Practice Address - Phone:254-519-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130942363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816036Medicaid