Healthcare Provider Details

I. General information

NPI: 1124132733
Provider Name (Legal Business Name): CHARLOTTE B. JOHNSON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 NORTH HILDALE ST.
HILDALE UT
84784-0459
US

IV. Provider business mailing address

1065 NORTH HILDALE ST.
HILDALE UT
84784-0459
US

V. Phone/Fax

Practice location:
  • Phone: 436-874-2217
  • Fax: 435-874-7805
Mailing address:
  • Phone: 436-874-2217
  • Fax: 435-874-7805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN101975
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number186597-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: