Provider Demographics
NPI:1437181104
Name:JOHNSON, MOLLY (NP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1578
Mailing Address - Country:US
Mailing Address - Phone:740-532-4858
Mailing Address - Fax:740-532-4859
Practice Address - Street 1:1408 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2301
Practice Address - Country:US
Practice Address - Phone:740-534-9195
Practice Address - Fax:740-534-9327
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4632P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2830119Medicaid
KY000000380503OtherANTHEM BCBS
KY78015401Medicaid
KY000000609842OtherANTHEM BCBS
WV1437181104Medicaid
KY0631725Medicare PIN