Provider Demographics
NPI:1194122267
Name:JOHNSTON, KEVIN W (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 TIMBERCREST LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1243
Mailing Address - Country:US
Mailing Address - Phone:631-922-5900
Mailing Address - Fax:631-675-9002
Practice Address - Street 1:33 TIMBERCREST LN
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1243
Practice Address - Country:US
Practice Address - Phone:631-922-5900
Practice Address - Fax:631-675-9002
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY689209163W00000X
NYF309196363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF309196OtherNY STATE OFFICE OF PROFESSIONS