Healthcare Provider Details

I. General information

NPI: 1275204604
Provider Name (Legal Business Name): MEGHAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11040 N STATE ROAD 77
HAYWARD WI
54843-3606
US

IV. Provider business mailing address

11040 N STATE ROAD 77
HAYWARD WI
54843-3606
US

V. Phone/Fax

Practice location:
  • Phone: 715-934-4910
  • Fax: 715-934-9620
Mailing address:
  • Phone: 715-934-4910
  • Fax: 715-934-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11477-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number227175-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: