Healthcare Provider Details

I. General information

NPI: 1184989881
Provider Name (Legal Business Name): KRISTEN LEE JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN LEE VICKS RN

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 E WATER ST
SYRACUSE NY
13210-1155
US

IV. Provider business mailing address

1226 E WATER ST
SYRACUSE NY
13210-1155
US

V. Phone/Fax

Practice location:
  • Phone: 315-478-4185
  • Fax:
Mailing address:
  • Phone: 315-478-4185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF337409-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: