Provider Demographics
NPI:1083855860
Name:JOHNSON, DEBRALEE DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:DEBRALEE
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DEBRALEE
Other - Middle Name:DENISE
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:928-697-4000
Mailing Address - Fax:928-697-4145
Practice Address - Street 1:HWY 160, S M.P. 394.3
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0368
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:928-697-4145
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171941163W00000X
AZ219637363LF0000X
NMR56240163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060012Medicaid
AZ030073Medicare Oscar/Certification
AZHSZ045Medicare PIN