Healthcare Provider Details

I. General information

NPI: 1780741777
Provider Name (Legal Business Name): EILEEN MARY JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4863 N NEVADA AVE SECOND FLOOR
COLORADO SPRINGS CO
80918-3951
US

IV. Provider business mailing address

3205 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917-5101
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax: 719-260-1821
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number62306
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0003418-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: