Provider Demographics
NPI:1215657978
Name:JOHNSON, KYNEA
Entity type:Individual
Prefix:
First Name:KYNEA
Middle Name:
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 1:70 NETTIE LN
Mailing Address - Street 2:
Mailing Address - City:MALLIE
Mailing Address - State:KY
Mailing Address - Zip Code:41836
Mailing Address - Country:US
Mailing Address - Phone:606-497-7852
Mailing Address - Fax:
Practice Address - Street 1:102 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9421
Practice Address - Country:US
Practice Address - Phone:606-439-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018034363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health