Provider Demographics
NPI:1023348430
Name:JOHNSON, LAURA LYNN (FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
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 550
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-0550
Mailing Address - Country:US
Mailing Address - Phone:541-830-0333
Mailing Address - Fax:541-830-0863
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-916-8530
Practice Address - Fax:541-916-8533
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050002NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616623Medicaid