=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043648462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATE JOHNSON CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2013
-----------------------------------------------------
Last Update Date | 10/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7940 WILLIAMS POND LN SUITE 150
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-8766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-209-4967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9120 KINGS CANYON DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-7676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-272-0215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | COA.14552-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------