MEDICARE: KYLE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1235690066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE JOHNSON

Provider Business Mailing Address
First Line	:	1809 BRIGHTON AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-1111
Country	:	US
Telephone Number	:	405-343-3305
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 BRIGHTON AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-1111
Country	:	US
Telephone Number	:	405-343-3305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	03/26/2019

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Directions to “ KYLE JOHNSON ” Practice Location

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