Provider Demographics
NPI:1891043402
Name:JOHNSON, MOLLY M (APRN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:M
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:3333 S 113TH ST # NEUSA
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4741
Mailing Address - Country:US
Mailing Address - Phone:402-616-6136
Mailing Address - Fax:
Practice Address - Street 1:505 S 45TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198
Practice Address - Country:US
Practice Address - Phone:402-559-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111412363L00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE111412OtherLICENSE NUMBER
NE098611095OtherMEDICARE PTAN