Provider Demographics
NPI:1992424493
Name:JOHNSON, BROOKE LAMETTA
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAMETTA
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:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40348-0185
Mailing Address - Country:US
Mailing Address - Phone:859-285-4768
Mailing Address - Fax:
Practice Address - Street 1:1365 DEVONPORT DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1552
Practice Address - Country:US
Practice Address - Phone:859-309-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1177547175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYJ03-973-942Medicaid