Provider Demographics
NPI:1144936766
Name:JOHNSON, KRISTEN (LMBT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 SUNCREEK CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-2263
Mailing Address - Country:US
Mailing Address - Phone:818-585-0880
Mailing Address - Fax:
Practice Address - Street 1:1333 BUCK JONES RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-3328
Practice Address - Country:US
Practice Address - Phone:919-443-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11168225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist