Healthcare Provider Details

I. General information

NPI: 1285515940
Provider Name (Legal Business Name): KATIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6137 S GLEN OAKS ST
MURRAY UT
84107-7658
US

IV. Provider business mailing address

6137 S GLEN OAKS ST
MURRAY UT
84107-7658
US

V. Phone/Fax

Practice location:
  • Phone: 801-440-7347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number7617894-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: