MEDICARE: PORTIA 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	171W00000X	Contractor

General Provider Information

NPI Number	:	1790482594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PORTIA JOHNSON

Provider Business Mailing Address
First Line	:	5835 N 36TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-4009
Country	:	US
Telephone Number	:	414-865-6622
Fax Number	:

Provider Business Practice Location Address
First Line	:	12250 W NORTH AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-2063
Country	:	US
Telephone Number	:	414-882-7881
Fax Number	:

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

Provider Enumeration Date	:	02/13/2023
Last Update Date	:	02/13/2023

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Directions to “ PORTIA JOHNSON ” Practice Location

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