Healthcare Provider Details

I. General information

NPI: 1134601248
Provider Name (Legal Business Name): WENDY LYNN JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 COUNTRY CLUB DR
LONGVIEW TX
75602-4713
US

IV. Provider business mailing address

113 COUNTRY CLUB DR
LONGVIEW TX
75602-4713
US

V. Phone/Fax

Practice location:
  • Phone: 903-452-9186
  • Fax:
Mailing address:
  • Phone: 903-452-9186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number873686
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: