MEDICARE: KATHLEEN MARIE JOHNSON AGACNP-BC

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	363LA2100X	Acute Care Nurse Practitioner	1109163	TX
2	363LG0600X	Gerontology Nurse Practitioner	1109163	TX
3	363LA2200X	Adult Health Nurse Practitioner	1109163	TX

General Provider Information

NPI Number	:	1245946680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE JOHNSON AGACNP-BC

Provider Business Mailing Address
First Line	:	112 CHAMPLAIN ST
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77905-3721
Country	:	US
Telephone Number	:	843-303-2147
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 E LOCUST AVE
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-3933
Country	:	US
Telephone Number	:	361-572-4300
Fax Number	:

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

Provider Enumeration Date	:	01/30/2023
Last Update Date	:	01/30/2023

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