Healthcare Provider Details

I. General information

NPI: 1922671767
Provider Name (Legal Business Name): KATELYN JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYN MORROW

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 RENAISSANCE DR
LOUISVILLE KY
40299-6206
US

IV. Provider business mailing address

4403 RENAISSANCE DR
LOUISVILLE KY
40299-6206
US

V. Phone/Fax

Practice location:
  • Phone: 502-424-5735
  • Fax:
Mailing address:
  • Phone: 502-424-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number1158143
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: