Healthcare Provider Details

I. General information

NPI: 1730910415
Provider Name (Legal Business Name): DALLIN STEPHEN RALPH JOHNSON PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 142
LAS VEGAS NV
89146-1050
US

IV. Provider business mailing address

6600 W CHARLESTON BLVD STE 142
LAS VEGAS NV
89146-1050
US

V. Phone/Fax

Practice location:
  • Phone: 702-440-8430
  • Fax: 866-640-0525
Mailing address:
  • Phone: 702-440-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number833966
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: