Healthcare Provider Details

I. General information

NPI: 1114014644
Provider Name (Legal Business Name): JOHANNA ELLEN FICKETT R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 KOT-NUM RD
WARM SPRINGS OR
97761
US

IV. Provider business mailing address

PO BOX 215
MADRAS OR
97741-0036
US

V. Phone/Fax

Practice location:
  • Phone: 541-553-1196
  • Fax: 541-553-2457
Mailing address:
  • Phone: 541-553-1196
  • Fax: 541-553-2457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number027695
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: