Provider Demographics
NPI:1619545027
Name:JOHNSON, KENYATTA LAFAYE (CERT NURSING ASSIST)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:LAFAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CERT NURSING ASSIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1546 MARTIN LUTHER KING JR AVE
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-9369
Mailing Address - Country:US
Mailing Address - Phone:863-473-1896
Mailing Address - Fax:
Practice Address - Street 1:1546 MARTIN LUTHER KING JR AVE
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-9369
Practice Address - Country:US
Practice Address - Phone:863-473-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health