Active NPI
Edalyn Kay Johnson, CNP
- Nurse Practitioner
- Albuquerque, NM
National Provider Identifier
1710935200
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- R17788
- Practice address
- 4550 Eubank Blvd NE
Suite 105
Albuquerque, NM 87111-3479 - Phone
- (505) 296-1120
- Fax
- (505) 296-1121
- NPI assigned
- May 5, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | R17788 | NM | |
| Nurse Practitioner | 363L00000X | R17788 | NM | Primary |
Addresses
Primary practice location
4550 Eubank Blvd NE
Suite 105
Albuquerque, NM 87111-3479
Mailing address
4550 Eubank Blvd NE
Suite 105
Albuquerque, NM 87111-3479
Phone (505) 296-1120
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 743032990 | Other | NM | TRIWEST |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Certified Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R17788 | NM | MD | Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146787200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1211241600000",
"number": "1710935200",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4550 EUBANK BLVD NE",
"address_2": "SUITE 105",
"city": "ALBUQUERQUE",
"state": "NM",
"postal_code": "871113479",
"telephone_number": "505-296-1120",
"fax_number": "505-296-1121"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4550 EUBANK BLVD NE",
"address_2": "SUITE 105",
"city": "ALBUQUERQUE",
"state": "NM",
"postal_code": "871113479",
"telephone_number": "505-296-1120",
"fax_number": "505-296-1121"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHNSON",
"first_name": "EDALYN",
"middle_name": "KAY",
"credential": "CNP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-05-05",
"last_updated": "2008-05-20",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "NM",
"license": "R17788",
"primary": false
},
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "NM",
"license": "R17788",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRIWEST",
"identifier": "743032990",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in Albuquerque, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.