Provider Demographics
NPI:1790096717
Name:JOHNSON, KRYSTAL GENEVA (MED, ATC)
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:GENEVA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 BREEZEPORT WAY
Mailing Address - Street 2:APT 203
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3808
Mailing Address - Country:US
Mailing Address - Phone:757-484-7477
Mailing Address - Fax:
Practice Address - Street 1:5838 HARBOUR VIEW BLVD
Practice Address - Street 2:STE 130
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2663
Practice Address - Country:US
Practice Address - Phone:757-673-5971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer