Provider Demographics
NPI:1700859261
Name:JOHNSON-ROSE, NANCY L (DO)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:JOHNSON-ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:JOHNSON-KERMODE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7481 HIGHWAY 65 69
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-9613
Mailing Address - Country:US
Mailing Address - Phone:515-953-1500
Mailing Address - Fax:515-953-2136
Practice Address - Street 1:7481 HIGHWAY 65 69
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-9613
Practice Address - Country:US
Practice Address - Phone:515-953-1500
Practice Address - Fax:515-953-2136
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0634550Medicaid
IA0634493Medicaid
P00445298OtherRAILROAD MEDICARE
IA1700859261Medicaid
IAI21103Medicare PIN
IA16-3455Medicare ID - Type UnspecifiedSULLY FAMILY HEALTH
IA16-3449Medicare ID - Type UnspecifiedMONROE FAMILY HEALTH
IA0634493Medicaid