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General NPI Number Information
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NPI Number | 1336810902
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Entity Type | Individual
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Provider Name | ELLY JOHNSON CNP
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Gender | Female
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Dates
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Enumeration Date | 09/23/2021
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 5009 S LOUISE AVE
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City | SIOUX FALLS
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State | SD
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Zip | 57108-2268
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Country | US
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Telephone | 605-799-1272
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Fax |
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Provider Business Mailing Address
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Address Line | 403 LIEN AVE
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City | HARRISBURG
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State | SD
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Zip | 57032-4312
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Country | US
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Telephone | 605-677-8093
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CP001949
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | R047341
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License Number State | SD
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