Healthcare Provider Details

I. General information

NPI: 1467286781
Provider Name (Legal Business Name): CRYSTAL JOHNSON RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17612 17TH ST STE A
TUSTIN CA
92780-1962
US

IV. Provider business mailing address

17612 17TH ST STE A
TUSTIN CA
92780-1962
US

V. Phone/Fax

Practice location:
  • Phone: 800-383-8180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95031925
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95364126
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number274396
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: