Provider Demographics
NPI:1174081715
Name:JOHNSON, TARA (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 E 134TH TER
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3357
Mailing Address - Country:US
Mailing Address - Phone:816-797-9353
Mailing Address - Fax:
Practice Address - Street 1:3801 BLUE PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64130-2807
Practice Address - Country:US
Practice Address - Phone:816-923-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-02
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78424363L00000X
MO2018032269363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner