Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 71011239A | IN |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 71011239A | IN |
NPI | 1255004313 |
---|---|
Provider Name | Janna Marie Johnson |
First Address | Charlestown, IN 47111-9535 |
Second Address | Charlestown, IN 47111-9535 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2021 |
Last Update Date | 08/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
300053678 | (05) | IN |
IN3604044 | MEDICARE IN (01) | IN |