Provider Demographics
NPI:1588794036
Name:JOHNSON, PENNY (LPN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27241 ROAD T.5
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-9415
Mailing Address - Country:US
Mailing Address - Phone:970-882-7463
Mailing Address - Fax:
Practice Address - Street 1:106 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3119
Practice Address - Country:US
Practice Address - Phone:970-565-3056
Practice Address - Fax:970-565-0647
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31704171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator