Provider Demographics
NPI:1861121287
Name:JOHNSON, BARBARA SUE
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:SUE
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 1:175 WALMART PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-7934
Mailing Address - Country:US
Mailing Address - Phone:606-340-3057
Mailing Address - Fax:606-340-9489
Practice Address - Street 1:175 WALMART PLAZA DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-7934
Practice Address - Country:US
Practice Address - Phone:606-340-3057
Practice Address - Fax:606-340-9489
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110050156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician