Healthcare Provider Details

I. General information

NPI: 1679368534
Provider Name (Legal Business Name): CRYSTAL W JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 E 300 S
SANTAQUIN UT
84655-5605
US

IV. Provider business mailing address

1092 E 300 S
SANTAQUIN UT
84655-5605
US

V. Phone/Fax

Practice location:
  • Phone: 435-660-9721
  • Fax:
Mailing address:
  • Phone: 435-660-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number5778123-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: