Healthcare Provider Details

I. General information

NPI: 1770124687
Provider Name (Legal Business Name): KEVIN JOHNSON MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 11/27/2023
Certification Date: 04/22/2020
Deactivation Date: 12/11/2019
Reactivation Date: 01/15/2020

III. Provider practice location address

1055 N 500 W STE 205
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-8095
  • Fax:
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8262328-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: