Provider Demographics
NPI:1265652598
Name:JOHNSON, KATHLEEN MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 W WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1101
Mailing Address - Country:US
Mailing Address - Phone:623-979-3480
Mailing Address - Fax:
Practice Address - Street 1:4650 W. SWEETWATER
Practice Address - Street 2:
Practice Address - City:GLND
Practice Address - State:AZ
Practice Address - Zip Code:85304
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:602-347-2709
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN033369251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ559114Medicaid