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General NPI Number Information
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NPI Number | 1164980611
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Entity Type | Individual
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Provider Name | MR. MITCHELL STEVEN JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 03/04/2019
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Last Update Date | 03/04/2019
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Provider Practice Location Address
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Address Line | 350 CONSTANCE BLVD
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City | WILLIAMS BAY
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State | WI
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Zip | 53191-9547
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Country | US
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Telephone | 262-245-5531
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Fax |
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Provider Business Mailing Address
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Address Line | 1303 SCOTTSWOOD RD
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City | ROCKFORD
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State | IL
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Zip | 61107-2063
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Country | US
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Telephone | 815-378-4999
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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