Provider Demographics
NPI:1144194739
Name:JOHNSON, MICAH GELANI
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:GELANI
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6408 BRIDGE RD APT 242
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1832
Mailing Address - Country:US
Mailing Address - Phone:908-229-8633
Mailing Address - Fax:
Practice Address - Street 1:800 ALGOMA BLVD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3551
Practice Address - Country:US
Practice Address - Phone:920-424-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI264928-30390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program