Healthcare Provider Details

I. General information

NPI: 1053640656
Provider Name (Legal Business Name): PATRICE JOHNELL MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21610 PACIFIC HWY
OCEAN PARK WA
98640-9864
US

IV. Provider business mailing address

4468 CLIPPER CV
DESTIN FL
32541-3699
US

V. Phone/Fax

Practice location:
  • Phone: 360-665-3000
  • Fax:
Mailing address:
  • Phone: 970-371-7120
  • Fax: 850-650-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-128942
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-9246598
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-10143
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60697111
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: