Provider Demographics
NPI:1063536571
Name:JOHNSON, KRYSTAL MICHELE
Entity type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:MICHELE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OAKLAND AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2019
Mailing Address - Country:US
Mailing Address - Phone:248-758-9813
Mailing Address - Fax:248-758-9815
Practice Address - Street 1:31 OAKLAND AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2019
Practice Address - Country:US
Practice Address - Phone:248-758-9813
Practice Address - Fax:248-758-9815
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5681890001171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4641944Medicaid
MI4641944Medicaid