Provider Demographics
NPI:1710935200
Name:JOHNSON, EDALYN KAY (CNP)
Entity Type:Individual
Prefix:
First Name:EDALYN
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 EUBANK BLVD NE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3479
Mailing Address - Country:US
Mailing Address - Phone:505-296-1120
Mailing Address - Fax:505-296-1121
Practice Address - Street 1:4550 EUBANK BLVD NE
Practice Address - Street 2:SUITE 105
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3479
Practice Address - Country:US
Practice Address - Phone:505-296-1120
Practice Address - Fax:505-296-1121
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR17788163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM743032990OtherTRIWEST
S47909Medicare UPIN
NM$$$$$$$$$RMedicare PIN