Provider Demographics
NPI:1619904935
Name:JOHNSON, GWEN S (MSN, RN, NPC)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, RN, NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7562 TRAILWIND DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5954
Mailing Address - Country:US
Mailing Address - Phone:513-615-8374
Mailing Address - Fax:
Practice Address - Street 1:3000 HOSPITAL DR STE 130
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1921
Practice Address - Country:US
Practice Address - Phone:513-735-8924
Practice Address - Fax:513-735-1740
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNP05049363LF0000X
OH05049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP90084Medicare UPIN