Provider Demographics
NPI:1316976962
Name:JOHNSON, LAVONNE LYNN (CRNP)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LAVONNE
Other - Middle Name:LYNN
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:7 DINWIDDIE CT
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 DINWIDDIE CT
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325
Practice Address - Country:US
Practice Address - Phone:717-337-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007903363LF0000X
MDR161084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD462MM822Medicare ID - Type UnspecifiedMD MEDICARE
MDQ55354Medicare UPIN