Provider Demographics
NPI:1992217707
Name:JOHNSON, KRISTINA ESTELLE (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ESTELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2662 LOHR DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7806
Mailing Address - Country:US
Mailing Address - Phone:843-801-2074
Mailing Address - Fax:
Practice Address - Street 1:2662
Practice Address - Street 2:LOHR DR
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466
Practice Address - Country:US
Practice Address - Phone:843-801-2074
Practice Address - Fax:843-801-2074
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty