Provider Demographics
NPI:1639665763
Name:JOHNSON, LANIE E (PAC)
Entity Type:Individual
Prefix:
First Name:LANIE
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LANIE
Other - Middle Name:E
Other - Last Name:RUDIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-0350
Mailing Address - Fax:414-805-6864
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-0350
Practice Address - Fax:414-805-6864
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639665763Medicaid