Provider Demographics
NPI:1740140664
Name:KJ WELLNESS NP IN ADULT HEALTH PLLC
Entity type:Organization
Organization Name:KJ WELLNESS NP IN ADULT HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP, RN
Authorized Official - Phone:631-336-0190
Mailing Address - Street 1:445 BROADHOLLOW RD STE 25
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3645
Mailing Address - Country:US
Mailing Address - Phone:631-336-0190
Mailing Address - Fax:
Practice Address - Street 1:445 BROADHOLLOW RD STE 25
Practice Address - Street 2:SUITE 25
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3645
Practice Address - Country:US
Practice Address - Phone:631-223-8852
Practice Address - Fax:631-350-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty