Basic Information
| Provider Information | |||||||||
| NPI: | 1124475058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | HOLLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3409 LUDINGTON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498294212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067894414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3409 LUDINGTON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498294212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067894414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704278219 | MI | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 4704278219 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.