Healthcare Provider Details

I. General information

NPI: 1578963179
Provider Name (Legal Business Name): KAYLA RENEE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W CARMEL DR STE 101
CARMEL IN
46032-5875
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 317-846-2396
  • Fax: 317-846-1699
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002926A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number02657
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: