Provider Demographics
NPI:1033144100
Name:RICKMAN-JOHNSON, DEIDRA L (CRNA)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:L
Last Name:RICKMAN-JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11686
Mailing Address - Street 2:NAPS INC
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339
Mailing Address - Country:US
Mailing Address - Phone:304-346-7313
Mailing Address - Fax:304-744-9802
Practice Address - Street 1:4701 MACCORKLE AVE
Practice Address - Street 2:THE DAY SURGERY CENTER
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-925-9300
Practice Address - Fax:304-925-9287
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29857367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0065221000Medicaid
WV27005299700OtherBRICKSTREET
WV27005299700OtherBRICKSTREET