Provider Demographics
NPI:1134417280
Name:JOHNSON, CAROLYN ILENE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ILENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5228 E EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:LA PORTE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50651-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516 DIVISION ST STE 110
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-2381
Practice Address - Country:US
Practice Address - Phone:319-268-3550
Practice Address - Fax:319-268-3855
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA102947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner