Provider Demographics
NPI:1942656079
Name:JOHNSON, HENRY LEE (RN)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4616
Mailing Address - Country:US
Mailing Address - Phone:608-220-1786
Mailing Address - Fax:
Practice Address - Street 1:4612 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-4616
Practice Address - Country:US
Practice Address - Phone:608-220-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157216163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse