Healthcare Provider Details

I. General information

NPI: 1851502892
Provider Name (Legal Business Name): SUSAN JOHNSON RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

IV. Provider business mailing address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

V. Phone/Fax

Practice location:
  • Phone: 86-609-3782
  • Fax: 208-946-4172
Mailing address:
  • Phone: 208-660-9378
  • Fax: 208-946-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number143199
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: