Healthcare Provider Details

I. General information

NPI: 1942428883
Provider Name (Legal Business Name): ELIZABETH JOHANSSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BERGEN ST
NEWARK NJ
07107-3000
US

IV. Provider business mailing address

26 WITHERSPOON ST
WHITEHOUSE STATION NJ
08889-3915
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-2513
  • Fax:
Mailing address:
  • Phone: 908-534-4096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NO09780800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: