Healthcare Provider Details

I. General information

NPI: 1265804900
Provider Name (Legal Business Name): JOHNNA FORMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST FL 4
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

138 LEADER AVE RM 252
LEXINGTON KY
40508-3215
US

V. Phone/Fax

Practice location:
  • Phone: 859-218-2581
  • Fax: 859-257-1632
Mailing address:
  • Phone: 859-323-5962
  • Fax: 859-323-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3011059
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number3011059
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3011059
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: