Healthcare Provider Details

I. General information

NPI: 1962228205
Provider Name (Legal Business Name): JANINE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 W INDIAN SCHOOL RD
PHOENIX AZ
85031
US

IV. Provider business mailing address

1675 S 172ND DR
GOODYEAR AZ
85338-1771
US

V. Phone/Fax

Practice location:
  • Phone: 623-691-4088
  • Fax:
Mailing address:
  • Phone: 623-418-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number253671
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: