Provider Demographics
NPI:1811606874
Name:JOHNSON, MISTIE DARLENE
Entity type:Individual
Prefix:MISS
First Name:MISTIE
Middle Name:DARLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 W POISON SPIDER RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-9507
Mailing Address - Country:US
Mailing Address - Phone:307-277-7352
Mailing Address - Fax:
Practice Address - Street 1:8700 W POISON SPIDER RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-9507
Practice Address - Country:US
Practice Address - Phone:307-277-7352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator