Provider Demographics
NPI:1457320327
Name:JOHNSON, KRISTIN MARIAH (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIAH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1078
Mailing Address - Country:US
Mailing Address - Phone:406-285-3251
Mailing Address - Fax:406-285-6742
Practice Address - Street 1:16 RAILWAY AVE.
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752
Practice Address - Country:US
Practice Address - Phone:406-285-3251
Practice Address - Fax:406-285-6742
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP720A363LF0000X
MT29346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00269935OtherRAILROAD RETIREMENT BOARD
IDNPWR5OtherBLUE CROSS
ID807303400Medicaid
ID000010152871OtherBLUE SHIELD
ID000010152871OtherBLUE SHIELD