MEDICARE: MARY P JOHNSON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	050895	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	175118	OTHER	MO	MO BLUE SHIELD
4	98337	OTHER	AZ	ARK BLUE SHIELD

General Provider Information

NPI Number	:	1407993496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY P JOHNSON CRNA

Provider Business Mailing Address
First Line	:	PO BOX 2580
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65801-2580
Country	:	US
Telephone Number	:	417-829-4620
Fax Number	:	471-829-4316

Provider Business Practice Location Address
First Line	:	1235 E CHEROKEE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2203
Country	:	US
Telephone Number	:	417-820-2829
Fax Number	:	417-820-8852

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	02/08/2026

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