=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891649448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL EDGE JOHNSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2026
-----------------------------------------------------
Last Update Date | 02/23/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 N ORANGE AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32801-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-414-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 W POPLAR ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-414-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------