Provider Demographics
NPI:1497039622
Name:JOHNSON, KRISTIN LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LYNN
Last Name:JOHNSON
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 1:249 WOODHULL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1327
Mailing Address - Country:US
Mailing Address - Phone:631-258-8294
Mailing Address - Fax:
Practice Address - Street 1:249 WOODHULL AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1327
Practice Address - Country:US
Practice Address - Phone:631-258-8294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY628344-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse