Provider Demographics
NPI:1104951409
Name:JOHNSON, SHARON A (FNP)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2820
Mailing Address - Country:US
Mailing Address - Phone:219-866-4135
Mailing Address - Fax:219-866-0803
Practice Address - Street 1:124 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2820
Practice Address - Country:US
Practice Address - Phone:219-866-4135
Practice Address - Fax:219-866-0803
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001610A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ4145Medicaid
Q01376Medicare UPIN