Provider Demographics
NPI:1225653512
Name:JOHNSON, CHANNEL (NP)
Entity Type:Individual
Prefix:MISS
First Name:CHANNEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 S CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4610
Mailing Address - Country:US
Mailing Address - Phone:918-932-8266
Mailing Address - Fax:918-932-8244
Practice Address - Street 1:1728 S CARSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4610
Practice Address - Country:US
Practice Address - Phone:918-932-8266
Practice Address - Fax:918-932-8244
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily