Healthcare Provider Details

I. General information

NPI: 1770307936
Provider Name (Legal Business Name): LIANE MARIE JOHNSTON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

1319 W 11TH ST
GRAFTON ND
58237-2138
US

V. Phone/Fax

Practice location:
  • Phone: 701-352-4059
  • Fax: 701-352-9290
Mailing address:
  • Phone: 701-352-4059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL10558
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL10558
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: