MEDICARE: CHARLOTTE B. JOHNSON CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	RN101975	AZ
2	363LP0200X	Pediatric Nurse Practitioner	186597-4405	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	197617	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1124132733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE B. JOHNSON CPNP

Provider Business Mailing Address
First Line	:	1065 NORTH HILDALE ST.
Second Line	:
City	:	HILDALE
State	:	UT
Zip	:	84784-0459
Country	:	US
Telephone Number	:	436-874-2217
Fax Number	:	435-874-7805

Provider Business Practice Location Address
First Line	:	1065 NORTH HILDALE ST.
Second Line	:
City	:	HILDALE
State	:	UT
Zip	:	84784-0459
Country	:	US
Telephone Number	:	436-874-2217
Fax Number	:	435-874-7805

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	02/05/2013

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