Provider Demographics
NPI:1811010796
Name:JOHNSON, KATHLEEN C (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3155
Mailing Address - Country:US
Mailing Address - Phone:321-724-2229
Mailing Address - Fax:321-728-6668
Practice Address - Street 1:330 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3155
Practice Address - Country:US
Practice Address - Phone:321-724-2229
Practice Address - Fax:321-728-6668
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1949352367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012338500Medicaid
FL012338500Medicaid