Provider Demographics
NPI:1215462056
Name:JOHNSON, MIKAELA (RN)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MARGARET ST.
Mailing Address - Street 2:
Mailing Address - City:COMBINED LOCKS
Mailing Address - State:WI
Mailing Address - Zip Code:54113
Mailing Address - Country:US
Mailing Address - Phone:920-843-1187
Mailing Address - Fax:
Practice Address - Street 1:509 MARGARET ST
Practice Address - Street 2:
Practice Address - City:COMBINED LOCKS
Practice Address - State:WI
Practice Address - Zip Code:54113-1312
Practice Address - Country:US
Practice Address - Phone:920-843-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI199748163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health