=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437573508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENT ALAN JOHNSON NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2014
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 N LINCOLN BLVD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73105-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-344-2128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 MAIN ST # 619
-----------------------------------------------------
City | CANON CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81212-3732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-344-2128
-----------------------------------------------------
Fax | 918-642-5639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | C.RXN.0100341-C-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 86602
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | C-APN.0100511-C-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------