Provider Demographics
NPI:1033506100
Name:JOHNSON, KENRA EARLINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KENRA
Middle Name:EARLINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19805 N 51ST AVE STE 33
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5198
Mailing Address - Country:US
Mailing Address - Phone:480-209-2849
Mailing Address - Fax:
Practice Address - Street 1:19805 N 51ST AVE STE 33
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5198
Practice Address - Country:US
Practice Address - Phone:480-209-2849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily