Basic Information
| Provider Information | |||||||||
| NPI: | 1629679782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | AILI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1604 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256465296 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1604 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256465296 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F102001180 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MJ16510069 | 01 | TX | DEA | OTHER | Q00086344 | 01 | RR PTAN | OTHER | 15154247 | 01 | CAQH | OTHER |