Provider Demographics
NPI:1518935717
Name:JOHNSON, MARY THERESE (RN, APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:BALS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, APRN
Mailing Address - Street 1:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1185
Mailing Address - Country:US
Mailing Address - Phone:715-552-5346
Mailing Address - Fax:
Practice Address - Street 1:1221 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5270
Practice Address - Country:US
Practice Address - Phone:715-552-5346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2374-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41195400Medicaid
WI41195400Medicaid