Provider Demographics
NPI:1942462825
Name:JOHNSON, LEEANN (FNP)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
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 1:3570 W 9000 S
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8869
Mailing Address - Country:US
Mailing Address - Phone:801-569-1999
Mailing Address - Fax:801-569-2001
Practice Address - Street 1:3570 W 9000 S
Practice Address - Street 2:STE 100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8869
Practice Address - Country:US
Practice Address - Phone:801-569-1999
Practice Address - Fax:801-569-2001
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295486-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT295486-4408OtherLICENSE
UT1164672770Medicaid
UT295486-4408OtherLICENSE
P00679723Medicare PIN