Healthcare Provider Details

I. General information

NPI: 1609018498
Provider Name (Legal Business Name): RENEE LYN JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 15TH AVE S STE 206
GREAT FALLS MT
59405-4334
US

IV. Provider business mailing address

401 15TH AVE S STE 206
GREAT FALLS MT
59405-4334
US

V. Phone/Fax

Practice location:
  • Phone: 406-727-2121
  • Fax: 406-452-5397
Mailing address:
  • Phone: 406-727-2121
  • Fax: 406-452-5397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7771250-1250
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMED-PHYS-LIC-76293
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2012-0854
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMED-PHYS-LIC-76923
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: