Healthcare Provider Details

I. General information

NPI: 1245406347
Provider Name (Legal Business Name): MANDY J JOHNSON WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 E 5900 S B-104
MURRAY UT
84107-7257
US

IV. Provider business mailing address

166 EAST 5900 SOUTH B-104
MURRAY UT
84107-7257
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-1266
  • Fax: 801-265-0755
Mailing address:
  • Phone: 801-265-1266
  • Fax: 801-265-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number362724-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: