Provider Demographics
NPI:1053640656
Name:JOHNELL, PATRICE (MSN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:PATRICE
Middle Name:
Last Name:JOHNELL
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4468 CLIPPER CV
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3699
Mailing Address - Country:US
Mailing Address - Phone:970-371-7120
Mailing Address - Fax:850-650-3774
Practice Address - Street 1:21610 PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:OCEAN PARK
Practice Address - State:WA
Practice Address - Zip Code:98640-9864
Practice Address - Country:US
Practice Address - Phone:360-665-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN-128942163W00000X
FLRN-9246598163W00000X
CONP-10143363LF0000X
WAAP60697111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28528506Medicaid
CO28528506Medicaid
COCOA104942Medicare PIN