Healthcare Provider Details

I. General information

NPI: 1194100412
Provider Name (Legal Business Name): KRISTINE JOHNSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 NATIONAL AVE NW APT 6
GRAND RAPIDS MI
49504-5594
US

IV. Provider business mailing address

325 NATIONAL AVE NW APT 6
GRAND RAPIDS MI
49504-5594
US

V. Phone/Fax

Practice location:
  • Phone: 616-589-8778
  • Fax:
Mailing address:
  • Phone: 616-589-8778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberJ523478040704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: