Healthcare Provider Details

I. General information

NPI: 1912619701
Provider Name (Legal Business Name): ILLYA JOHNSON-HICKLEN RCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2022
Last Update Date: 12/23/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND, ROUTE N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278C0205X
TaxonomyCritical Care Certified Respiratory Therapist
License NumberRCP02003641
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: