Provider Demographics
NPI:1518789924
Name:JOHNSON, NATHANIEL LEE
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:LEE
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 1:430 KERR IS N
Mailing Address - Street 2:
Mailing Address - City:ROME CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46784-9675
Mailing Address - Country:US
Mailing Address - Phone:260-438-9839
Mailing Address - Fax:
Practice Address - Street 1:1355 MARINERS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-7145
Practice Address - Country:US
Practice Address - Phone:574-372-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030836A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist