Healthcare Provider Details

I. General information

NPI: 1255116430
Provider Name (Legal Business Name): CANDACE CHAQUELLE' JOHNSON MBA, DNP, APRN,FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 11/05/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 GARDEN OF GODS RD STE 2044
COLORADO SPRINGS CO
80907-9444
US

IV. Provider business mailing address

1675 GARDEN OF GODS RD STE 2044
COLORADO SPRINGS CO
80907-9444
US

V. Phone/Fax

Practice location:
  • Phone: 719-578-3199
  • Fax: 719-578-3114
Mailing address:
  • Phone: 719-578-3199
  • Fax: 719-578-3114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0999045
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: