Provider Demographics
NPI:1104442250
Name:JOHNSON, KAYLA MCCROSKEY
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MCCROSKEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:BOISSEVAIN
Mailing Address - State:VA
Mailing Address - Zip Code:24606-0247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1934 LEATHERWOOD LN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2019
Practice Address - Country:US
Practice Address - Phone:762-596-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV105609363LF0000X
VA0024179198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily