Provider Demographics
NPI:1124318159
Name:JOHNSON, LYNN COOPER (FNP)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:COOPER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:COOPER
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:5551 S WHITE MOUNTAIN RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7449
Mailing Address - Country:US
Mailing Address - Phone:928-985-1495
Mailing Address - Fax:
Practice Address - Street 1:914 N SAN FRANCISCO ST STE D
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3254
Practice Address - Country:US
Practice Address - Phone:928-243-0244
Practice Address - Fax:928-597-5198
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN168022163WE0003X
AZAP5735363LF0000X
AZAP11496363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily