Provider Demographics
NPI:1154531564
Name:JOHNSEN, NANCY GAYTON
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:GAYTON
Last Name:JOHNSEN
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 1:1811 S SOWELL ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4660
Mailing Address - Country:US
Mailing Address - Phone:559-636-8271
Mailing Address - Fax:
Practice Address - Street 1:310 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5009
Practice Address - Country:US
Practice Address - Phone:559-734-6042
Practice Address - Fax:559-635-4788
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA545416Medicaid