Provider Demographics
NPI:1548809528
Name:JOHNSON, KRISTA
Entity type:Individual
Prefix:MRS
First Name:KRISTA
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:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:SIMMESPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71369-0144
Mailing Address - Country:US
Mailing Address - Phone:800-462-0742
Mailing Address - Fax:318-941-2388
Practice Address - Street 1:417 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369-2181
Practice Address - Country:US
Practice Address - Phone:800-462-0742
Practice Address - Fax:318-941-2388
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA211416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program