=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902167364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASSIE SOEFJE JOHNSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2012
-----------------------------------------------------
Last Update Date | 06/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 COURTHOUSE XING
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41051-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-356-6800
-----------------------------------------------------
Fax | 859-363-4073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 635283
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-5283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-356-6800
-----------------------------------------------------
Fax | 859-363-4073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TP198
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2020-03203
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | Q1632
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 2020-03203
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 59606
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------