Provider Demographics
NPI:1164588018
Name:JOHNSON, KRISTIN D
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
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 651602
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-1602
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1375 APRN367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863OtherTRICARE
SC576007863OtherBCBS
SCAN0960Medicaid
SC430062058OtherMEDICARE RAILROAD
SCQ32551Medicare UPIN
SCQ325513365Medicare PIN