Healthcare Provider Details

I. General information

NPI: 1639250863
Provider Name (Legal Business Name): DEBRA A JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10030 GILEAD RD
HUNTERSVILLE NC
28078-7545
US

IV. Provider business mailing address

160 POLIDIS ROAD
MOORESVILLE NC
28112
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-4274
  • Fax: 704-384-5636
Mailing address:
  • Phone: 704-799-0865
  • Fax: 704-384-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number038200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: