Healthcare Provider Details

I. General information

NPI: 1528449691
Provider Name (Legal Business Name): ANDREW JOHANNEMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S LIMESTONE CTW 304
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

900 S LIMESTONE CTW 304
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax:
Mailing address:
  • Phone: 859-323-9918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR3812
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: