Healthcare Provider Details

I. General information

NPI: 1417467010
Provider Name (Legal Business Name): ROBERT JOHNSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HARDIN LN STE A
SOMERSET KY
42503
US

IV. Provider business mailing address

104 HARDIN LN STE A
SOMERSET KY
42503-3800
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-8323
  • Fax: 606-678-0496
Mailing address:
  • Phone: 606-678-8323
  • Fax: 606-451-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3011600
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3011600
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: