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General NPI Number Information
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NPI Number | 1609219682
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Entity Type | Individual
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Provider Name | ANNELYSSA NICOLE JOHNSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/09/2013
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Last Update Date | 11/12/2020
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Provider Practice Location Address
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Address Line | 1701 N SENATE BLVD # AG012
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-1239
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Country | US
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Telephone | 317-962-3525
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Fax | 317-963-5394
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Provider Business Mailing Address
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Address Line | 1350 W VAN BUREN ST APT 1071
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City | PHOENIX
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State | AZ
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Zip | 85007-2575
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Country | US
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Telephone | 520-406-0309
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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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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | DR.0056541
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License Number State | CO
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