Healthcare Provider Details

I. General information

NPI: 1275715948
Provider Name (Legal Business Name): HEIDI L JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N MAIN ST
SPEARFISH SD
57783-1505
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN CHRISTIE MSS
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-644-4000
  • Fax: 605-644-4006
Mailing address:
  • Phone: 605-644-4000
  • Fax: 605-644-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR000682
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: