Healthcare Provider Details

I. General information

NPI: 1114320405
Provider Name (Legal Business Name): COOPER JOHNSON NP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N MAIN STREET
TAYLOR AZ
85939
US

IV. Provider business mailing address

PO BOX 889
OVERGAARD AZ
85933-0889
US

V. Phone/Fax

Practice location:
  • Phone: 928-536-4322
  • Fax: 928-536-2395
Mailing address:
  • Phone: 928-535-6667
  • Fax: 928-535-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP5735
License Number StateAZ

VIII. Authorized Official

Name: MR. LYNN COOPER JOHNSON
Title or Position: OWNER
Credential: NP
Phone: 928-243-1770