Provider Demographics
NPI:1265873335
Name:JOHNSON, KRISTIN MARIE (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5694 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8845
Mailing Address - Country:US
Mailing Address - Phone:989-695-2123
Mailing Address - Fax:989-695-2316
Practice Address - Street 1:5694 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-8845
Practice Address - Country:US
Practice Address - Phone:989-695-2123
Practice Address - Fax:989-695-2316
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant