Provider Demographics
NPI:1740256742
Name:JOHNSON, MARISSA LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
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 1:1215 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-5129
Mailing Address - Country:US
Mailing Address - Phone:830-379-5867
Mailing Address - Fax:830-401-4035
Practice Address - Street 1:1215 E COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5129
Practice Address - Country:US
Practice Address - Phone:830-379-5867
Practice Address - Fax:830-401-4035
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTBN573224367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX312189901Medicaid
178028300OtherDOL
TX8554UDOtherBCBS
Q14728Medicare UPIN
TX312189901Medicaid