Healthcare Provider Details

I. General information

NPI: 1124318159
Provider Name (Legal Business Name): LYNN COOPER JOHNSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: COOPER JOHNSON FNP

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 N SAN FRANCISCO ST STE D
FLAGSTAFF AZ
86001-3254
US

IV. Provider business mailing address

5551 S WHITE MOUNTAIN RD UNIT 2
SHOW LOW AZ
85901-7449
US

V. Phone/Fax

Practice location:
  • Phone: 928-243-0244
  • Fax: 928-597-5198
Mailing address:
  • Phone: 928-985-1495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN168022
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP5735
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11496
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: