Provider Demographics
NPI:1508204033
Name:JOHNSTON, ANDREA RAE (LAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RAE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 BROWNSBORO GLEN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1198
Mailing Address - Country:US
Mailing Address - Phone:714-357-7347
Mailing Address - Fax:
Practice Address - Street 1:306 MIDDLETOWN PARK PL STE C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2517
Practice Address - Country:US
Practice Address - Phone:502-742-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAC082171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist