Provider Demographics
NPI:1003108499
Name:JOHNSON, NADINE IRENE (RN)
Entity Type:Individual
Prefix:MRS
First Name:NADINE
Middle Name:IRENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-8420
Mailing Address - Country:US
Mailing Address - Phone:928-346-4679
Mailing Address - Fax:928-346-4686
Practice Address - Street 1:1607 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440-8420
Practice Address - Country:US
Practice Address - Phone:928-346-4679
Practice Address - Fax:928-346-4686
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA710223163W00000X
AZRN153520163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse