Healthcare Provider Details

I. General information

NPI: 1669510525
Provider Name (Legal Business Name): DALE J JOHNSON RN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DALE J GOULD

II. Dates (important events)

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

III. Provider practice location address

7 WHARF ROAD BOLINAS FAMILY PRACTICE
BOLINAS CA
94924
US

IV. Provider business mailing address

POB 906 230 ALDER DRIVE
BOLINAS CA
94924
US

V. Phone/Fax

Practice location:
  • Phone: 415-868-1578
  • Fax: 415-868-2152
Mailing address:
  • Phone: 415-868-1578
  • Fax: 415-868-2152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberV303572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: