Provider Demographics
NPI:1336322627
Name:JOHNSON, JOLENE LALLISS (NNP)
Entity Type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:LALLISS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 N 200 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4642
Mailing Address - Country:US
Mailing Address - Phone:801-296-2624
Mailing Address - Fax:
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3221574405363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal