Basic Information
| Provider Information | |||||||||
| NPI: | 1063707263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHRISTIN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAVRE | ||||||||
| OtherFirstName: | CHRISTIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1987 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776852164 | ||||||||
| FaxNumber: | 3177055060 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 S CARMEL ST | ||||||||
| Address2: | |||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496012547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318763876 | ||||||||
| FaxNumber: | 2317751115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 244764 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 4704258522 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 176K2 | 01 | NC | BCBS NC | OTHER |