Provider Demographics
NPI:1093391708
Name:JOHNSON, KASSIE LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:KASSIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 DOWNALONG DR
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1159
Mailing Address - Country:US
Mailing Address - Phone:304-532-5302
Mailing Address - Fax:
Practice Address - Street 1:6040 UNIVERSITY TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2421
Practice Address - Country:US
Practice Address - Phone:304-598-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program