=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720804081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA JOHNSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 MONTGOMERY BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-804-1547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 MESA DEL SOL CT
-----------------------------------------------------
City | LOS LUNAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87031-9749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-804-1547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LN0000X
-----------------------------------------------------
Taxonomy Name | Neonatal Nurse Practitioner
-----------------------------------------------------
License Number | 81779
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------