Provider Demographics
NPI:1437119021
Name:JOHNSON, PEGGY A (CRNA)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:A
Other - Last Name:HERNDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:143 REATTA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-5058
Mailing Address - Country:US
Mailing Address - Phone:940-626-1556
Mailing Address - Fax:940-627-1425
Practice Address - Street 1:143 REATTA DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-5058
Practice Address - Country:US
Practice Address - Phone:940-626-1556
Practice Address - Fax:940-627-1425
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX441025163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse