MEDICARE: MARY ELLEN JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse		WI

General Provider Information

NPI Number	:	1669697827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN JOHNSON

Provider Business Mailing Address
First Line	:	2212 N 36TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1407
Country	:	US
Telephone Number	:	414-442-3781
Fax Number	:

Provider Business Practice Location Address
First Line	:	2212 N 36TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1407
Country	:	US
Telephone Number	:	414-442-3781
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	07/08/2007

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