Provider Demographics
NPI:1003938606
Name:JOHANSEN, BETTY ANN (RN,C,FNP)
Entity Type:Individual
Prefix:MISS
First Name:BETTY
Middle Name:ANN
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:RN,C,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 COLORADO BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6872
Mailing Address - Country:US
Mailing Address - Phone:940-566-2358
Mailing Address - Fax:940-381-2613
Practice Address - Street 1:3304 COLORADO BLVD STE 101
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6872
Practice Address - Country:US
Practice Address - Phone:940-566-2358
Practice Address - Fax:940-381-2613
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229039363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS71169Medicare UPIN
TX85N141Medicare ID - Type Unspecified