Provider Demographics
NPI:1699067546
Name:JOHNSON, FREDRICK G (CRNFA)
Entity type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 E EAGLE DR
Mailing Address - Street 2:#20730
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-3031
Mailing Address - Country:US
Mailing Address - Phone:480-229-7254
Mailing Address - Fax:
Practice Address - Street 1:4320 E PRESIDIO ST
Practice Address - Street 2:#101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:480-706-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN143974163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant