Provider Demographics
NPI:1962458182
Name:JOHNSON, JUDITH M (MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3343 N WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1213
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:
Practice Address - Street 1:WEST YAVAPAI GUIDANCE CLINIC
Practice Address - Street 2:625 HILLSIDE AVENUE
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-771-8483
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-02022363LF0000X, 363LP0808X
AZAP3355363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ276768Medicare ID - Type Unspecified