Provider Demographics
NPI:1619369410
Name:JOHANNESSEN, KRISTEN (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:JOHANNESSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GETTYSBURG RD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6713
Mailing Address - Country:US
Mailing Address - Phone:707-315-0987
Mailing Address - Fax:
Practice Address - Street 1:5450 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4601
Practice Address - Country:US
Practice Address - Phone:734-671-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine