Healthcare Provider Details

I. General information

NPI: 1477984326
Provider Name (Legal Business Name): FA-TIA JOHNSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5566 N 37TH ST
MILWAUKEE WI
53209-4734
US

IV. Provider business mailing address

5566 N 37TH ST
MILWAUKEE WI
53209-4734
US

V. Phone/Fax

Practice location:
  • Phone: 414-324-8479
  • Fax:
Mailing address:
  • Phone: 414-324-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03357
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number198325-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: