1326198243 NPI number — MS. BETTY LOUANN JOHNSON MA

Table of content: MS. BETTY LOUANN JOHNSON MA (NPI 1326198243)

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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