Provider Demographics
NPI:1730197070
Name:JOHNSON, WANDA R (AUDIOLOGIST)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:R
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUDIOLOGIST
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2580
Mailing Address - Country:US
Mailing Address - Phone:402-421-0896
Mailing Address - Fax:402-421-0945
Practice Address - Street 1:575 S 70TH ST
Practice Address - Street 2:STE 440
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2471
Practice Address - Country:US
Practice Address - Phone:402-484-5500
Practice Address - Fax:402-484-5501
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2422355A2700X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37016OtherBCBS
NE36809OtherBCBS
NE10025369300Medicaid
NE10025369400Medicaid
NEP00855060OtherRAILROAD MEDICARE
NE100249918 00Medicaid
279879Medicare PIN
NE099747003Medicare PIN
NE10025369400Medicaid