Provider Demographics
NPI:1093423030
Name:JOHNSON, CAROL COLENE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:COLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 NS 3570 RD
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-9238
Mailing Address - Country:US
Mailing Address - Phone:203-561-7122
Mailing Address - Fax:
Practice Address - Street 1:701 CEDAR LAKE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7815
Practice Address - Country:US
Practice Address - Phone:405-445-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK210538363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily