Provider Demographics
NPI:1912326158
Name:JOHNSON, VANESSA GAYLE (DO)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:GAYLE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:DO
Other - Prefix:MISS
Other - First Name:VANESSA
Other - Middle Name:GAYLE
Other - Last Name:GAINEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:787 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:SALYERSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41465-9740
Mailing Address - Country:US
Mailing Address - Phone:606-349-3511
Mailing Address - Fax:
Practice Address - Street 1:787 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:SALYERSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41465-9740
Practice Address - Country:US
Practice Address - Phone:606-349-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY04102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100520750Medicaid