Provider Demographics
NPI:1588964381
Name:JOHNSON, NANCY ELLEN
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 OLD MAMMOTH RD
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546
Mailing Address - Country:US
Mailing Address - Phone:760-934-4337
Mailing Address - Fax:760-934-8097
Practice Address - Street 1:481 OLD MAMMOTH ROAD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-934-4337
Practice Address - Fax:760-934-8097
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist