Provider Demographics
NPI:1265494785
Name:JOHNSON, DUSTY (CRNA)
Entity type:Individual
Prefix:MRS
First Name:DUSTY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:DUSTY
Other - Middle Name:
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:643 RAY LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-1439
Mailing Address - Country:US
Mailing Address - Phone:706-745-9068
Mailing Address - Fax:
Practice Address - Street 1:35 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3139
Practice Address - Country:US
Practice Address - Phone:610-453-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC282190367500000X
PARN514136L367500000X
GARN275163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104122OtherGEISINGER
PA20053633OtherMERCY
PA50058155OtherKEYSTONE HEALTH PLAN CENTRAL
PA50058155OtherCAPITAL BLUE CROSS
PA001833846OtherHIGHMARK
PA7598828OtherAETNA-NON HMO
PAP00298903OtherRR MEDICARE
PA2689279000OtherINDEPENDENCE BLUE CROSS
PA1278934OtherAETNA-HMO
PA50058155OtherKEYSTONE HEALTH PLAN CENTRAL