Provider Demographics
NPI:1588002323
Name:JOHANNSEN, LORI LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LYNN
Last Name:JOHANNSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:JOHANNSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:IA
Mailing Address - Zip Code:51442-2607
Mailing Address - Country:US
Mailing Address - Phone:712-265-2700
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2607
Practice Address - Country:US
Practice Address - Phone:712-265-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant