Provider Demographics
NPI:1376265314
Name:JOHSTONO, CRYSTAL IVY (RN)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:IVY
Last Name:JOHSTONO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CHARTER BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4831
Mailing Address - Country:US
Mailing Address - Phone:478-757-6000
Mailing Address - Fax:
Practice Address - Street 1:2932 VICTORIA CIR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1254
Practice Address - Country:US
Practice Address - Phone:478-960-7622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN088169208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice