Healthcare Provider Details

I. General information

NPI: 1285900605
Provider Name (Legal Business Name): CODY D JOHNSTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 BURKARTH RD
WARRENSBURG MO
64093-3101
US

IV. Provider business mailing address

247 NE 71ST RD
WARRENSBURG MO
64093-7407
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2500
  • Fax: 660-747-8455
Mailing address:
  • Phone: 479-739-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number89932
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: