=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528895703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KISHA LATASHA JOHNSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2024
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11408 LAKE SHERWOOD AVE N STE A
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70816-0421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-261-7143
-----------------------------------------------------
Fax | 225-250-1026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508 E MARTIN LUTHER KING JR DR
-----------------------------------------------------
City | ABBEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70510-6866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-500-8805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------