Healthcare Provider Details

I. General information

NPI: 1689797953
Provider Name (Legal Business Name): MONA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONA JOHNSON WHCNP

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 DUNES PLZ
MICHIGAN CITY IN
46360-7342
US

IV. Provider business mailing address

19265 KERN RD
SOUTH BEND IN
46614-5720
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-7215
  • Fax:
Mailing address:
  • Phone: 574-231-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number28074373A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: