Provider Demographics
NPI:1942428883
Name:JOHANSSON, ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JOHANSSON
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 1:26 WITHERSPOON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:08889-3915
Mailing Address - Country:US
Mailing Address - Phone:908-534-4096
Mailing Address - Fax:
Practice Address - Street 1:30 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3000
Practice Address - Country:US
Practice Address - Phone:973-972-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO09780800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ035070Medicare ID - Type Unspecified