Provider Demographics
NPI:1629802319
Name:JOHNSON, HEATHER DANELLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DANELLE
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 1:207 PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3749
Mailing Address - Country:US
Mailing Address - Phone:501-628-5580
Mailing Address - Fax:501-628-5583
Practice Address - Street 1:207 PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3749
Practice Address - Country:US
Practice Address - Phone:501-628-5580
Practice Address - Fax:501-628-5583
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR78242163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics