Healthcare Provider Details

I. General information

NPI: 1194717611
Provider Name (Legal Business Name): TERRY JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LORETTO RD
LEBANON KY
40033-1300
US

IV. Provider business mailing address

425 LEWIS HARGETT CIR
LEXINGTON KY
40503-3590
US

V. Phone/Fax

Practice location:
  • Phone: 270-692-3161
  • Fax:
Mailing address:
  • Phone: 859-268-1030
  • Fax: 859-269-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3000970
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: