Provider Demographics
NPI:1326443284
Name:JOHNSON, CRYSTAL SHANTAE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:SHANTAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WATERBROOK TER
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2933
Mailing Address - Country:US
Mailing Address - Phone:404-281-7385
Mailing Address - Fax:
Practice Address - Street 1:3903 S COBB DR SE
Practice Address - Street 2:SUITE 225
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8504
Practice Address - Country:US
Practice Address - Phone:770-434-1904
Practice Address - Fax:770-434-1304
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF0914437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily