1790096717 NPI number — MISS KRYSTAL GENEVA JOHNSON M.ED., ATC

Table of content: MISS KRYSTAL GENEVA JOHNSON M.ED., ATC (NPI 1790096717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790096717 NPI number — MISS KRYSTAL GENEVA JOHNSON M.ED., ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KRYSTAL
Provider Middle Name:
GENEVA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.ED., ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790096717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3919 BREEZEPORT WAY
Provider Second Line Business Mailing Address:
APT 203
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23435-3808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-484-7477
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5838 HARBOUR VIEW BLVD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23435-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-673-5971
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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