Provider Demographics
NPI:1528799103
Name:JOHNSON, ALICE JOAN (MSN, APRN)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:JOAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 LIMESTONE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8313
Mailing Address - Country:US
Mailing Address - Phone:801-410-2293
Mailing Address - Fax:
Practice Address - Street 1:990 LIMESTONE DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8313
Practice Address - Country:US
Practice Address - Phone:801-410-2293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ID67196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program