Healthcare Provider Details

I. General information

NPI: 1235794371
Provider Name (Legal Business Name): RYAN LAYNE KALEO JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SMITH RD
NEWPORT RI
02841-1006
US

IV. Provider business mailing address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-4335
  • Fax:
Mailing address:
  • Phone: 702-624-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: