Provider Demographics
NPI:1104085497
Name:JOHNSON, MARY BETH (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:LELONEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2322 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7205
Mailing Address - Country:US
Mailing Address - Phone:563-355-1853
Mailing Address - Fax:563-359-1512
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-355-1853
Practice Address - Fax:563-359-1512
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF-100600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner