Provider Demographics
NPI:1578963179
Name:JOHNSON, KAYLA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:755 W CARMEL DR STE 101
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5875
Practice Address - Country:US
Practice Address - Phone:317-846-2396
Practice Address - Fax:317-846-1699
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10002926A363A00000X
WV02657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant