Provider Demographics
NPI:1275737637
Name:JOHNSON, KRISTA FAYRE
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:FAYRE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:NY
Mailing Address - Zip Code:14541-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5783 E LAKE RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:NY
Practice Address - Zip Code:14541-5002
Practice Address - Country:US
Practice Address - Phone:315-585-6063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program