Provider Demographics
NPI:1518953629
Name:JOHNSON, MARY ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-8473
Mailing Address - Fax:319-356-2587
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-8473
Practice Address - Fax:319-356-2587
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAJ0534502084P0805X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04876OtherWELLMARK BCBS
IA0420596Medicaid
IA0420596Medicaid
IA04876Medicare PIN