Provider Demographics
NPI:1124132733
Name:JOHNSON, CHARLOTTE B (CPNP)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 NORTH HILDALE ST.
Mailing Address - Street 2:
Mailing Address - City:HILDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84784-0459
Mailing Address - Country:US
Mailing Address - Phone:436-874-2217
Mailing Address - Fax:435-874-7805
Practice Address - Street 1:1065 NORTH HILDALE ST.
Practice Address - Street 2:
Practice Address - City:HILDALE
Practice Address - State:UT
Practice Address - Zip Code:84784-0459
Practice Address - Country:US
Practice Address - Phone:436-874-2217
Practice Address - Fax:435-874-7805
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN101975363LP0200X
UT186597-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ197617OtherAHCCCS