Provider Demographics
NPI:1881183325
Name:JOHNSON, KATELYN KANE
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:KANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ELIZABETH
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3202
Mailing Address - Country:US
Mailing Address - Phone:203-688-4242
Mailing Address - Fax:
Practice Address - Street 1:70 KENYON AVE STE 210
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4253
Practice Address - Country:US
Practice Address - Phone:401-788-8780
Practice Address - Fax:401-788-8787
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIMD19358208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program