Healthcare Provider Details

I. General information

NPI: 1669965505
Provider Name (Legal Business Name): KATELYN S JOHNSTON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-4361
US

IV. Provider business mailing address

4500 13TH ST
GULFPORT MS
39501-2515
US

V. Phone/Fax

Practice location:
  • Phone: 228-818-1111
  • Fax:
Mailing address:
  • Phone: 228-575-2902
  • Fax: 228-575-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901511
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: