Provider Demographics
NPI:1376630673
Name:JOHNSON, KATHLEEN ANNE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-1805
Mailing Address - Country:US
Mailing Address - Phone:541-479-8858
Mailing Address - Fax:541-479-8859
Practice Address - Street 1:1692 WILLIAMS HWY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-1805
Practice Address - Country:US
Practice Address - Phone:541-479-8858
Practice Address - Fax:541-479-8859
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650113NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily