Healthcare Provider Details

I. General information

NPI: 1275737637
Provider Name (Legal Business Name): KRISTA FAYRE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5783 E LAKE RD
ROMULUS NY
14541-5002
US

IV. Provider business mailing address

5783 E LAKE RD
ROMULUS NY
14541-5002
US

V. Phone/Fax

Practice location:
  • Phone: 315-585-6063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: