Basic Information
| Provider Information | |||||||||
| NPI: | 1285157255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2944 BRECKENRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402201409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST UNIT 510 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884800 | ||||||||
| FaxNumber: | 5025884801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2017 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3011519 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 300007363 | 05 | IN | MEDICAID | 7100487900 | 05 | KY | MEDICAID |