Provider Demographics
NPI:1679354997
Name:JOHNSON, KATHRYN MARY CERVINO (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY CERVINO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-2345
Mailing Address - Country:US
Mailing Address - Phone:919-593-3149
Mailing Address - Fax:
Practice Address - Street 1:932 MORREENE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4410
Practice Address - Country:US
Practice Address - Phone:919-668-2879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018960363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner