Provider Demographics
NPI:1710266473
Name:JOHNSON, BRENDA LENAE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:BRENDA
Other - Middle Name:LENAE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 4TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-1940
Mailing Address - Country:US
Mailing Address - Phone:605-697-5352
Mailing Address - Fax:605-610-1561
Practice Address - Street 1:306 4TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1940
Practice Address - Country:US
Practice Address - Phone:605-697-5352
Practice Address - Fax:605-610-1561
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000650363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD20110813516668Medicaid