Basic Information
Provider Information | |||||||||
NPI: | 1659862068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | THERESA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUNN | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | THERESA | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 12625 HESPERIA RD | ||||||||
Address2: |   | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923957720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609958300 | ||||||||
FaxNumber: | 7609552356 | ||||||||
Practice Location | |||||||||
Address1: | 1841 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BARSTOW | ||||||||
State: | CA | ||||||||
PostalCode: | 923113234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602555700 | ||||||||
FaxNumber: | 7602565092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2018 | ||||||||
LastUpdateDate: | 05/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 610741 | CA | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.