MEDICARE: KRISTI JO 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	R22652	ND

General Provider Information

NPI Number	:	1770501322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTI JO JOHNSON CRNA

Provider Business Mailing Address
First Line	:	4307 RIVERWOOD DR N
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58102-5324
Country	:	US
Telephone Number	:	701-361-4146
Fax Number	:	701-239-1779

Provider Business Practice Location Address
First Line	:	3280 20TH ST S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-5917
Country	:	US
Telephone Number	:	701-293-7408
Fax Number	:

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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