Provider Demographics
NPI:1811013469
Name:JOHNSON, KATHRYN (RN,NP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3427
Mailing Address - Country:US
Mailing Address - Phone:831-475-3951
Mailing Address - Fax:831-475-3951
Practice Address - Street 1:412 CEDAR ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4369
Practice Address - Country:US
Practice Address - Phone:831-425-3337
Practice Address - Fax:831-466-0366
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA509229363LP0808X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050890Medicaid
CAGR0050890Medicaid