Provider Demographics
NPI:1083458368
Name:JOHNSON, KAEDE
Entity type:Individual
Prefix:
First Name:KAEDE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 N MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4011
Mailing Address - Country:US
Mailing Address - Phone:831-402-9404
Mailing Address - Fax:
Practice Address - Street 1:3112 N MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4011
Practice Address - Country:US
Practice Address - Phone:831-402-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife