Healthcare Provider Details

I. General information

NPI: 1861319105
Provider Name (Legal Business Name): COREY JAMES JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 N 78TH ST
OMAHA NE
68114-3640
US

IV. Provider business mailing address

339 N 78TH ST
OMAHA NE
68114-3640
US

V. Phone/Fax

Practice location:
  • Phone: 402-315-3788
  • Fax:
Mailing address:
  • Phone: 402-315-3788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number117007
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: