Provider Demographics
NPI:1104821982
Name:JOHNSON, MARLA SMITH (APRN)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:SMITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-331-0774
Mailing Address - Fax:859-578-3800
Practice Address - Street 1:900 MEDICAL VILLAGE DR
Practice Address - Street 2:MEDI
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-331-0774
Practice Address - Fax:859-578-3800
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003587363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00942703OtherRAIL ROAD MEDICARE
KYP00954941OtherRAIL ROAD MEDDICARE
OH0052920Medicaid
500023900OtherPALMETTO GBA-RAILROAD MEDICARE
KY78006681Medicaid
000000225922OtherANTHEM
IN201127110Medicaid
IN201127110Medicaid
KYP400041788Medicare PIN
KY0551834Medicare PIN