Provider Demographics
NPI:1609912450
Name:JOHNSON, ROXANNE M (FNP)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 9TH ST SW # 2
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4644
Mailing Address - Country:US
Mailing Address - Phone:701-952-9600
Mailing Address - Fax:701-845-8067
Practice Address - Street 1:110 9TH ST SW # 2
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4644
Practice Address - Country:US
Practice Address - Phone:701-952-9600
Practice Address - Fax:701-952-9601
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22212363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19721Medicaid
NDN718610Medicare PIN
ND19721Medicaid