Provider Demographics
NPI:1336810902
Name:JOHNSON, ELLY (CNP)
Entity Type:Individual
Prefix:
First Name:ELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 LIEN AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-4312
Mailing Address - Country:US
Mailing Address - Phone:605-677-8093
Mailing Address - Fax:
Practice Address - Street 1:5009 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2268
Practice Address - Country:US
Practice Address - Phone:605-799-1272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001949363LF0000X
SDR047341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse