Healthcare Provider Details

I. General information

NPI: 1194882951
Provider Name (Legal Business Name): CAROL ANN HOMIAK JOHNSON R.N.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S 6TH AVE
TUCSON AZ
85723-0001
US

IV. Provider business mailing address

4173 E CALLE MARFIL
TUCSON AZ
85712-6408
US

V. Phone/Fax

Practice location:
  • Phone: 520-792-1450
  • Fax:
Mailing address:
  • Phone: 520-797-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN045272
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: