1326198243 NPI number — MS. BETTY LOUANN JOHNSON MA

Table of content: SARAH MONIQUE JACKSON (NPI 1780867101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326198243 NPI number — MS. BETTY LOUANN JOHNSON MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
BETTY
Provider Middle Name:
LOUANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ASWEGAN
Provider Other First Name:
KITTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326198243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNEY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68848-1328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-440-8054
Provider Business Mailing Address Fax Number:
308-234-6604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2210 30TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEARNEY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68845-9687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-440-8054
Provider Business Practice Location Address Fax Number:
308-234-6604
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LADC 305 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LMHP 294 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 713406000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025064900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025131100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025131000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84769 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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