Healthcare Provider Details

I. General information

NPI: 1235164963
Provider Name (Legal Business Name): ELLEN A JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PERRI AVENUE
MYERSTOWN PA
17067-3200
US

IV. Provider business mailing address

PO BOX 300 4TH & WILLOW STREET
LEBANON PA
17042-0300
US

V. Phone/Fax

Practice location:
  • Phone: 717-949-6581
  • Fax: 717-949-2070
Mailing address:
  • Phone: 171-272-4451
  • Fax: 717-272-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD039460E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD039460E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: