Provider Demographics
NPI:1790424760
Name:JOHNSON, KENDALLYN
Entity Type:Individual
Prefix:
First Name:KENDALLYN
Middle Name:
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 1:103 CLEARFIELD CIR APT A
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1858
Mailing Address - Country:US
Mailing Address - Phone:804-930-3507
Mailing Address - Fax:
Practice Address - Street 1:5115 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-5000
Practice Address - Country:US
Practice Address - Phone:757-683-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-29
Last Update Date:2022-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine