Provider Demographics
NPI:1619331436
Name:JOHNSON, ALYSIA (NNP)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
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:PO BOX 1627
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:TX
Mailing Address - Zip Code:79782-1627
Mailing Address - Country:US
Mailing Address - Phone:432-661-3935
Mailing Address - Fax:
Practice Address - Street 1:520 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4527
Practice Address - Country:US
Practice Address - Phone:432-582-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX791930363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal