Basic Information
| Provider Information | |||||||||
| NPI: | 1942462825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LEEANN | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3570 W 9000 S | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840888869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015691999 | ||||||||
| FaxNumber: | 8015692001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3570 W 9000 S | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840888869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015691999 | ||||||||
| FaxNumber: | 8015692001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 295486-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 295486-4408 | 01 | UT | LICENSE | OTHER | 1164672770 | 05 | UT | MEDICAID |