Provider Demographics
NPI:1508483173
Name:JOHNSTON, ANGELA KIRSTEN (NP-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:KIRSTEN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:KIRSTEN
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:422 CHESAPEAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1674
Mailing Address - Country:US
Mailing Address - Phone:208-851-2381
Mailing Address - Fax:
Practice Address - Street 1:2243 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6519
Practice Address - Country:US
Practice Address - Phone:208-851-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID65180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily