Healthcare Provider Details

I. General information

NPI: 1194300533
Provider Name (Legal Business Name): HEATHER ELIZABETH MARIE JOHNSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 PINEHURST RD SE
RIO RANCHO NM
87124-2568
US

IV. Provider business mailing address

918 PINEHURST RD SE STE 102
RIO RANCHO NM
87124-2568
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-9555
  • Fax:
Mailing address:
  • Phone: 505-404-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number63068
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: