Basic Information
Provider Information | |||||||||
NPI: | 1538245691 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | KRISTINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1145 S. UTICA AVENUE | ||||||||
Address2: | SUITE 110 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741044013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185793826 | ||||||||
FaxNumber: | 9185791262 | ||||||||
Practice Location | |||||||||
Address1: | 1265 S. UTICA AVE. | ||||||||
Address2: | SUITE 105 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741044243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184937800 | ||||||||
FaxNumber: | 9184937868 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 05/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 100145 | OK | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 100145 | 01 | OK | FIRST ASSISTANT CERTIFICA | OTHER |