Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 3006871 | KY |
NPI | 1700177292 |
---|---|
Provider Name | Jill M Johnson |
First Address | Corbin, KY 40701-2735 |
Second Address | Gray, KY 40734-4536 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2011 |
Last Update Date | 02/07/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100167610 | (05) | KY |