Provider Demographics
NPI:1134383466
Name:JOHNSON, KENNETH W
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RWPETRUSO HEARING AND AUDIOLOGY CENTER, INC
Mailing Address - Street 2:937 PARK AVE
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3334
Mailing Address - Country:US
Mailing Address - Phone:814-724-6211
Mailing Address - Fax:814-337-0188
Practice Address - Street 1:RW PETRUSO HEARING AND AUDIOLOGY CENTER, INC
Practice Address - Street 2:8001 ROWAN RD, SUITE 201
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-3619
Practice Address - Country:US
Practice Address - Phone:724-779-4327
Practice Address - Fax:724-779-4329
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X
OH03087237700000X
PAF03513237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician