Provider Demographics
NPI:1427701572
Name:JOHNSON, KORYLEA (FNP-C)
Entity type:Individual
Prefix:
First Name:KORYLEA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KORYLEA
Other - Middle Name:
Other - Last Name:LEBRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:7875 RAINCROSS CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0011
Mailing Address - Country:US
Mailing Address - Phone:209-556-7894
Mailing Address - Fax:
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-782-3721
Practice Address - Fax:951-784-3269
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-29
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019832363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner