Provider Demographics
NPI:1417467010
Name:JOHNSON, ROBERT (NP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HARDIN LN STE A
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3800
Mailing Address - Country:US
Mailing Address - Phone:606-678-8323
Mailing Address - Fax:606-451-0963
Practice Address - Street 1:104 HARDIN LN STE A
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-678-8323
Practice Address - Fax:606-678-0496
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011600363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology