Provider Demographics
NPI:1770191728
Name:JOHNSON, KISSY L
Entity Type:Individual
Prefix:
First Name:KISSY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1040
Mailing Address - Country:US
Mailing Address - Phone:314-737-1141
Mailing Address - Fax:
Practice Address - Street 1:7045 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:MO
Practice Address - Zip Code:63136-1040
Practice Address - Country:US
Practice Address - Phone:314-737-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health