Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 28150798A | IN |
NPI | 1003165275 |
---|---|
Provider Name | Mrs. Kristin M Johnson |
First Address | Evansville, IN 47710-5191 |
Second Address | Evansville, IN 47710-5191 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2012 |
Last Update Date | 04/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100246550A | (05) | IN |
C25864 | (02) | IN |