Provider Demographics
NPI:1497830574
Name:JOHNSON, BETTE T (APN)
Entity Type:Individual
Prefix:MS
First Name:BETTE
Middle Name:T
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 1:2500 NEFF RD.
Mailing Address - Street 2:ST CHARLES MEDICAL CENTER
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:92201-0001
Mailing Address - Country:US
Mailing Address - Phone:541-706-5675
Mailing Address - Fax:
Practice Address - Street 1:2500 NEFF RD.
Practice Address - Street 2:ST CHARLES MEDICAL CENTER
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:92201-0001
Practice Address - Country:US
Practice Address - Phone:541-706-5675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN276756L363LN0000X, 363LN0005X, 363L00000X
OR200850071NP363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ16225Medicaid
MD4033701Medicaid
MD4033701Medicaid
NJ16225Medicaid