Provider Demographics
NPI:1558102590
Name:JOHNSON, HEIDI N/A
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:N/A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2297 OUTSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6308
Mailing Address - Country:US
Mailing Address - Phone:702-301-3032
Mailing Address - Fax:
Practice Address - Street 1:3930 HOWARD HUGHES PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-0946
Practice Address - Country:US
Practice Address - Phone:702-550-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN69200163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse