Provider Demographics
NPI:1831511807
Name:JOHNSON, KENNETH LARRY I
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LARRY
Last Name:JOHNSON
Suffix:I
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 1:216 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-6743
Mailing Address - Country:US
Mailing Address - Phone:954-294-5600
Mailing Address - Fax:
Practice Address - Street 1:216 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6743
Practice Address - Country:US
Practice Address - Phone:954-294-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)