Provider Demographics
NPI:1184642753
Name:JOHNSON, LUCY M (CNS)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1929
Mailing Address - Country:US
Mailing Address - Phone:701-234-3100
Mailing Address - Fax:701-234-3120
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-3100
Practice Address - Fax:701-234-3120
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR20985364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND70011Medicaid
ND70010Medicaid
MN300019200Medicaid
ND70011Medicaid
ND70010Medicaid
MN300019200Medicaid