Provider Demographics
NPI:1922044684
Name:JOHNSON, LAUREL D (CRNA)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:D
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 1:50 SHADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:PISGAH FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:28768-9501
Mailing Address - Country:US
Mailing Address - Phone:828-877-6462
Mailing Address - Fax:
Practice Address - Street 1:391 SERPENTINE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3096
Practice Address - Country:US
Practice Address - Phone:404-478-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2628532EMedicare ID - Type UnspecifiedCRNA