=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770307936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIANE MARIE JOHNSTON LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 ELM ST N
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58102-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-352-4059
-----------------------------------------------------
Fax | 701-352-9290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1319 W 11TH ST
-----------------------------------------------------
City | GRAFTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58237-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-352-4059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | L10558
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | L10558
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------