Provider Demographics
NPI:1144507757
Name:JOHNSON, BERNADETTE ANN (CRNA)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 AIRPORT CENTER PKWY BLDG L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5885
Mailing Address - Country:US
Mailing Address - Phone:704-512-7105
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-667-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20245A367500000X
NC195056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8054146Medicaid
SCNAN041Medicaid
SCNAN041Medicaid