Provider Demographics
NPI:1841618238
Name:JOHNSON, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
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 1:604 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66092-8829
Mailing Address - Country:US
Mailing Address - Phone:520-260-9962
Mailing Address - Fax:
Practice Address - Street 1:604 PINE ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66092-8829
Practice Address - Country:US
Practice Address - Phone:520-260-9962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN071834363LF0000X
KS53-14125284-092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily