Healthcare Provider Details

I. General information

NPI: 1194328831
Provider Name (Legal Business Name): MARCIE LEIGH JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 S US-25W W
WILLIAMSBURG KY
40769-1533
US

IV. Provider business mailing address

55 BLANTON SUBDIVISION RD
LONDON KY
40741-8256
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-5052
  • Fax: 606-549-2718
Mailing address:
  • Phone: 606-308-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015451
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: