Provider Demographics
NPI:1285068122
Name:JOHANNES, MARY T (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:JOHANNES
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 1:3300 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3402
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:11111 M ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2378
Practice Address - Country:US
Practice Address - Phone:402-504-4099
Practice Address - Fax:402-504-3929
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71410163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse