Provider Demographics
NPI:1659862068
Name:JOHNSON, KATHLEEN THERESA (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:THERESA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:THERESA
Other - Last Name:HUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12625 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7720
Mailing Address - Country:US
Mailing Address - Phone:760-995-8300
Mailing Address - Fax:760-955-2356
Practice Address - Street 1:1841 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3234
Practice Address - Country:US
Practice Address - Phone:760-255-5700
Practice Address - Fax:760-256-5092
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA610741163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health