Provider Demographics
NPI:1639250863
Name:JOHNSON, DEBRA A (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 POLIDIS ROAD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28112
Mailing Address - Country:US
Mailing Address - Phone:704-799-0865
Mailing Address - Fax:704-384-5636
Practice Address - Street 1:10030 GILEAD RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7545
Practice Address - Country:US
Practice Address - Phone:704-384-4274
Practice Address - Fax:704-384-5636
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC038200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered