Provider Demographics
NPI:1497746549
Name:JOHNSON, KENNETH M (LPN)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14018 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1308
Mailing Address - Country:US
Mailing Address - Phone:301-776-1771
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8394
Practice Address - Fax:301-677-8876
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP24559164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLP24559OtherLICENSED PRACTICAL NURSE