Provider Demographics
NPI:1396840211
Name:JOHNSON, LISA ANN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:HOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4940 CORRALES RD STE 125
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8682
Mailing Address - Country:US
Mailing Address - Phone:505-433-4446
Mailing Address - Fax:
Practice Address - Street 1:4940 CORRALES RD STE 125
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8682
Practice Address - Country:US
Practice Address - Phone:505-433-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368977-4405363L00000X
NM54024363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ53493Medicare UPIN