Provider Demographics
NPI:1629067228
Name:JOHNSON, DAYLE E (FNP)
Entity Type:Individual
Prefix:
First Name:DAYLE
Middle Name:E
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 1:105 RIDGECREST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7807
Mailing Address - Country:US
Mailing Address - Phone:417-725-8250
Mailing Address - Fax:417-725-8253
Practice Address - Street 1:105 RIDGECREST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7807
Practice Address - Country:US
Practice Address - Phone:417-725-8250
Practice Address - Fax:417-725-8253
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004000194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S88447Medicare UPIN