Provider Demographics
NPI:1962048264
Name:JOHNSON, ALLYSA KYLEE (LPN)
Entity type:Individual
Prefix:
First Name:ALLYSA
Middle Name:KYLEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 1/2 MOTT ST
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-1540
Mailing Address - Country:US
Mailing Address - Phone:716-489-6602
Mailing Address - Fax:
Practice Address - Street 1:221 1/2 MOTT ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1540
Practice Address - Country:US
Practice Address - Phone:716-489-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337007164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse