Provider Demographics
NPI:1457025793
Name:JOHNSON, KRISTINA
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
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 1:12497 HARD DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968
Mailing Address - Country:US
Mailing Address - Phone:302-265-7212
Mailing Address - Fax:
Practice Address - Street 1:33672 BAYVIEW MEDICAL DR FL 1
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1687
Practice Address - Country:US
Practice Address - Phone:302-645-2437
Practice Address - Fax:833-629-0820
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE000000002084N0400X
DEC5-0011609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty