Provider Demographics
NPI:1679510309
Name:JOHNSON, MARY I (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:I
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:115 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3244
Practice Address - Country:US
Practice Address - Phone:573-882-4979
Practice Address - Fax:573-884-6050
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO048830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101660OtherHEALTHLINK
MO143538OtherBLUE SHIELD/BLUE CHOICE
MO425336609Medicaid
MO500020674Medicare PIN
MO101660OtherHEALTHLINK
MO425336609Medicaid
MOP00457828Medicare PIN
MO143538OtherBLUE SHIELD/BLUE CHOICE