Provider Demographics
NPI:1558665414
Name:JOHNSON, KERRY LYNN (PA)
Entity Type:Individual
Prefix:MISS
First Name:KERRY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 W 72ND ST
Mailing Address - Street 2:APT 1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2661
Mailing Address - Country:US
Mailing Address - Phone:631-944-5923
Mailing Address - Fax:
Practice Address - Street 1:635 BELLE TERRE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1935
Practice Address - Country:US
Practice Address - Phone:631-474-0008
Practice Address - Fax:631-474-0224
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113422995OtherTAX ID #