1740601319 NPI number — MRS. CRYSTAL RENEE JOHNSON LPN

Table of content: MRS. CRYSTAL RENEE JOHNSON LPN (NPI 1740601319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740601319 NPI number — MRS. CRYSTAL RENEE JOHNSON LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CRYSTAL
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PITTMAN
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740601319
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
254 MOUNT PROSPECT AVE. APT. 405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-676-2575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 BARTLETT STREET
Provider Second Line Business Practice Location Address:
WHITE GLOVE COMMUNITY CARE, INC
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-387-8181
Provider Business Practice Location Address Fax Number:
718-782-1538
Provider Enumeration Date:
12/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  278560 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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