Provider Demographics
NPI:1235675257
Name:JOHNSON, KASSIDY
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29219 HORSESHOE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-3557
Mailing Address - Country:US
Mailing Address - Phone:985-606-0279
Mailing Address - Fax:
Practice Address - Street 1:17000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3246
Practice Address - Country:US
Practice Address - Phone:225-755-4858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09181363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology