Healthcare Provider Details

I. General information

NPI: 1164795993
Provider Name (Legal Business Name): LISA R. JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5000
  • Fax:
Mailing address:
  • Phone: 314-996-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN177866
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024007274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: