Healthcare Provider Details

I. General information

NPI: 1821779448
Provider Name (Legal Business Name): CRYSTAL SUE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 S ASH ST
WICHITA KS
67216-3224
US

IV. Provider business mailing address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-641-1136
  • Fax:
Mailing address:
  • Phone: 316-641-1136
  • Fax: 316-469-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number13-127206
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: