Healthcare Provider Details

I. General information

NPI: 1003493826
Provider Name (Legal Business Name): MARY LYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 48TH ST
BOULDER CO
80303-1143
US

IV. Provider business mailing address

1505 48TH ST
BOULDER CO
80303-1143
US

V. Phone/Fax

Practice location:
  • Phone: 303-506-9439
  • Fax:
Mailing address:
  • Phone: 303-506-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1002166-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number0094898
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: