=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366877631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2013
-----------------------------------------------------
Last Update Date | 09/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 S FORDHAM DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85710-8758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-260-9962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 PINE ST
-----------------------------------------------------
City | WELLSVILLE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66092-8829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-260-9962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MSN/FNP-C
-----------------------------------------------------
Name | MRS. KATHLEEN ELIZABETH JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-260-9962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------