Provider Demographics
NPI:1831429992
Name:JOHNSON, MICHELLE L (CSA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2211 MAYFAIR DR
Mailing Address - Street 2:SUITE #410
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-4568
Mailing Address - Country:US
Mailing Address - Phone:270-685-1605
Mailing Address - Fax:270-685-5535
Practice Address - Street 1:2211 MAYFAIR DR
Practice Address - Street 2:SUITE #410
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4568
Practice Address - Country:US
Practice Address - Phone:270-685-1605
Practice Address - Fax:270-685-5535
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2818246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant