Individual
MARY ALICE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
1726 SHAWANO AVE, GREEN BAY, WI 54303-3216
(920) 498-4200
Mailing address
225 S EXECUTIVE DR, BROOKFIELD, WI 53005-4266
(262) 787-4026
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
66618-30
WI
367500000X
Certified Registered Nurse Anesthetist
Primary
033282
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43316600
—
WI
Enumeration date
03/01/2007
Last updated
07/21/2010
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