Provider Demographics
NPI:1780741777
Name:JOHNSON, EILEEN MARY (NP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:4863 N NEVADA AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3951
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-260-1821
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2017-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO62306363LG0600X
COAPN.0003418-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44857314Medicaid
COCO 305289OtherMEDICARE NUMBER