Basic Information
| Provider Information | |||||||||
| NPI: | 1780741777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7193447837 | ||||||||
| Practice Location | |||||||||
| Address1: | 4863 N NEVADA AVE | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7192601821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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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 | 363LG0600X | 62306 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LF0000X | APN.0003418-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 44857314 | 05 | CO | MEDICAID | CO 305289 | 01 | CO | MEDICARE NUMBER | OTHER |