Provider Demographics
NPI:1689604126
Name:JOHNSON, KRISTIN L (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
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 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-623-4077
Mailing Address - Fax:417-623-5171
Practice Address - Street 1:702 E 34TH STREET
Practice Address - Street 2:STE 203
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-623-4077
Practice Address - Fax:417-623-5171
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO144504363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118064OtherANTHEM
MO428626311Medicaid
OK100021980AMedicaid
KS100283520BMedicaid