Healthcare Provider Details

I. General information

NPI: 1033428636
Provider Name (Legal Business Name): CRYSTAL JOHNSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 02/10/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 COBURG RD STE 100
EUGENE OR
97401-4988
US

IV. Provider business mailing address

3587 HEATHROW WAY
MEDFORD OR
97504-4004
US

V. Phone/Fax

Practice location:
  • Phone: 458-210-2984
  • Fax: 458-210-2985
Mailing address:
  • Phone: 541-858-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number202100581RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: