Healthcare Provider Details

I. General information

NPI: 1760635387
Provider Name (Legal Business Name): RENEE JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6541 SPECKER AVE
FORT CARSON CO
80913-4263
US

IV. Provider business mailing address

174 MILLSTREAM TER
COLORADO SPRINGS CO
80905-4430
US

V. Phone/Fax

Practice location:
  • Phone: 719-503-7905
  • Fax:
Mailing address:
  • Phone: 719-466-0458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0168271
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: