Healthcare Provider Details

I. General information

NPI: 1225123888
Provider Name (Legal Business Name): MARYJAYNE MABREY JOHNSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6190 N SUNSHINE ST STE E
COEUR D ALENE ID
83815-8697
US

IV. Provider business mailing address

6190 N SUNSHINE ST STE E
COEUR D ALENE ID
83815-8697
US

V. Phone/Fax

Practice location:
  • Phone: 208-719-0311
  • Fax: 208-719-0301
Mailing address:
  • Phone: 208-719-0311
  • Fax: 208-719-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number197104-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026427
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1871154
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPT0007476
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: