Provider Demographics
NPI:1437200540
Name:JOHNSON, KRISTIN ELISE (MSN, RNCS)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ELISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11367 HUNTINGTON VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7523
Mailing Address - Country:US
Mailing Address - Phone:916-213-6766
Mailing Address - Fax:916-859-0677
Practice Address - Street 1:2377 GOLD MEADOW WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4405
Practice Address - Country:US
Practice Address - Phone:916-213-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209713 AND 74364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26956ZMedicare ID - Type UnspecifiedPROVIDER NUMBER
CAS66096Medicare UPIN