Basic Information
| Provider Information | |||||||||
| NPI: | 1518103241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | POTTER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRANKS | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | POTTER | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.P.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 413 VIRGO WAY | ||||||||
| Address2: | |||||||||
| City: | FRUITA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815219011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708587725 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2121 NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702420731 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 32320 | CO | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.