Healthcare Provider Details

I. General information

NPI: 1609288448
Provider Name (Legal Business Name): KANDICE E JOHNSON RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 EAST APPLEBY RD. SUITE 202
FAYETTEVILLE AR
72703-4424
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745
US

V. Phone/Fax

Practice location:
  • Phone: 479-404-1140
  • Fax: 479-404-1141
Mailing address:
  • Phone: 479-463-7775
  • Fax: 479-463-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR014870
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: