1710266473 NPI number — MRS. BRENDA LENAE JOHNSON CNP

Table of content: MRS. BRENDA LENAE JOHNSON CNP (NPI 1710266473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710266473 NPI number — MRS. BRENDA LENAE JOHNSON CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
BRENDA
Provider Middle Name:
LENAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
BRENDA
Provider Other Middle Name:
LENAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710266473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 4TH ST
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57006-1940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-697-5352
Provider Business Mailing Address Fax Number:
605-610-1561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 4TH ST
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-1940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-697-5352
Provider Business Practice Location Address Fax Number:
605-610-1561
Provider Enumeration Date:
08/12/2011

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: 363LP0808X , with the licence number:  CP000650 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20110813516668 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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