MEDICARE: CONNIE DENISE JOHNSON-WILTZ FNP-BC

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	363LF0000X	Family Nurse Practitioner	703409	TX

General Provider Information

NPI Number	:	1306354261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE DENISE JOHNSON-WILTZ FNP-BC

Provider Business Mailing Address
First Line	:	2933 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-1899
Fax Number	:	409-300-4310

Provider Business Practice Location Address
First Line	:	2933 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-1899
Fax Number	:	409-300-4310

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

Provider Enumeration Date	:	01/12/2018
Last Update Date	:	10/03/2023

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