Provider Demographics
NPI:1790897445
Name:JOHANSEN, DALE HOWARD (CRNA, MSN, ARNP)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:HOWARD
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:CRNA, MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-9755
Mailing Address - Country:US
Mailing Address - Phone:515-987-8241
Mailing Address - Fax:
Practice Address - Street 1:300 W HUTCHINGS ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-2109
Practice Address - Country:US
Practice Address - Phone:515-462-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD081538367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered