Provider Demographics
NPI:1982787560
Name:JOHANSEN, CHARLA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SOLDIERS PASS RD STE B1
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-4712
Mailing Address - Country:US
Mailing Address - Phone:928-204-4900
Mailing Address - Fax:
Practice Address - Street 1:95 SOLDIERS PASS RD STE B1
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4712
Practice Address - Country:US
Practice Address - Phone:928-204-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ234691363LG0600X
FL3234612363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology