Healthcare Provider Details

I. General information

NPI: 1194364752
Provider Name (Legal Business Name): KRISTA ANN JOHNSON MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13616 CALIFORNIA ST STE 100
OMAHA NE
68154-5336
US

IV. Provider business mailing address

13616 CALIFORNIA ST STE 100
OMAHA NE
68154-5336
US

V. Phone/Fax

Practice location:
  • Phone: 402-496-0404
  • Fax: 402-496-7766
Mailing address:
  • Phone: 402-496-0404
  • Fax: 402-496-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000026747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: