Provider Demographics
NPI:1043906993
Name:JOHNSON, ABIGAIL LYNN (RN)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:LYNN
Other - Last Name:HENEGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2975 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-3314
Mailing Address - Country:US
Mailing Address - Phone:618-315-8117
Mailing Address - Fax:
Practice Address - Street 1:2200 HAVASUPAI BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-3122
Practice Address - Country:US
Practice Address - Phone:928-505-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ288511163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool