Healthcare Provider Details

I. General information

NPI: 1841257896
Provider Name (Legal Business Name): CAROLEEN JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 W 9800 S #101
SOUTH JORDAN UT
84095-3211
US

IV. Provider business mailing address

3556 W 9800 S #101
SOUTH JORDAN UT
84095-3211
US

V. Phone/Fax

Practice location:
  • Phone: 801-567-9750
  • Fax: 801-567-9826
Mailing address:
  • Phone: 801-567-9780
  • Fax: 801-567-9826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number199209-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: