Healthcare Provider Details

I. General information

NPI: 1215657978
Provider Name (Legal Business Name): KYNEA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MEDICAL CENTER DR
HAZARD KY
41701-9421
US

IV. Provider business mailing address

70 NETTIE LN
MALLIE KY
41836
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-1331
  • Fax:
Mailing address:
  • Phone: 606-497-7852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3018034
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: