Provider Demographics
NPI:1609018498
Name:JOHNSON, RENEE LYN (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 15TH AVE S STE 206
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4334
Mailing Address - Country:US
Mailing Address - Phone:406-727-2121
Mailing Address - Fax:406-452-5397
Practice Address - Street 1:401 15TH AVE S STE 206
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4334
Practice Address - Country:US
Practice Address - Phone:406-727-2121
Practice Address - Fax:406-452-5397
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7771250-1250208000000X
MTMED-PHYS-LIC-76293208000000X
NMMD2012-0854208000000X
MTMED-PHYS-LIC-76923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics