Provider Demographics
NPI:1538623400
Name:JOHNSON, FAYE OPAL (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:FAYE
Middle Name:OPAL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 BASIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6649
Mailing Address - Country:US
Mailing Address - Phone:701-989-0268
Mailing Address - Fax:
Practice Address - Street 1:1033 BASIN AVE STE A
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6649
Practice Address - Country:US
Practice Address - Phone:701-989-0268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00014171100000X
ND1175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturist