Healthcare Provider Details

I. General information

NPI: 1679334353
Provider Name (Legal Business Name): KENNETHA DOREEN JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S BANK ST
MT STERLING KY
40353-1322
US

IV. Provider business mailing address

104 CATHERINE ST
CARLISLE KY
40311-1206
US

V. Phone/Fax

Practice location:
  • Phone: 859-520-3044
  • Fax: 859-520-3077
Mailing address:
  • Phone: 859-513-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number310019
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number310019
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: