Provider Demographics
NPI:1770307936
Name:JOHNSTON, LIANE MARIE (LPN)
Entity type:Individual
Prefix:
First Name:LIANE
Middle Name:MARIE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-2138
Mailing Address - Country:US
Mailing Address - Phone:701-352-4059
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-352-4059
Practice Address - Fax:701-352-9290
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL10558207Q00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty