Healthcare Provider Details

I. General information

NPI: 1174742035
Provider Name (Legal Business Name): KRISTINA ANNE JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 NE COURTNEY DR
BEND OR
97701-7638
US

IV. Provider business mailing address

2901 SW INDIAN CIR
REDMOND OR
97756-5512
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7412
  • Fax:
Mailing address:
  • Phone: 541-322-7412
  • Fax: 541-322-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number40324RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: