Provider Demographics
NPI:1356813612
Name:JOHNSON, CHARLOTTE REBECCA (C-AA)
Entity type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:REBECCA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:C-AA
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:REBECCA
Other - Last Name:WURTZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4034
Mailing Address - Fax:970-490-4347
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO367H00000X
COANT.0000099367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant