Provider Demographics
NPI:1063440030
Name:JOHNSON, SANDRA ELLEN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 DAVE COWANS DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-4570
Mailing Address - Country:US
Mailing Address - Phone:859-291-4800
Mailing Address - Fax:859-291-4801
Practice Address - Street 1:500 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1822
Practice Address - Country:US
Practice Address - Phone:906-635-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704152459367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered