Provider Demographics
NPI:1891125662
Name:JOHNSON, EMMYLU ABBIE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMMYLU
Middle Name:ABBIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMMYLU
Other - Middle Name:ABBIE
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:450 LAUREL ST STE A
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3045
Mailing Address - Country:US
Mailing Address - Phone:515-247-8400
Mailing Address - Fax:515-248-8888
Practice Address - Street 1:450 LAUREL ST STE A
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3045
Practice Address - Country:US
Practice Address - Phone:515-247-8400
Practice Address - Fax:515-248-8888
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA108148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant