Provider Demographics
NPI:1134897002
Name:JOHNSON, KATHRYN ANN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1118
Practice Address - Country:US
Practice Address - Phone:541-851-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA219751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program