Basic Information
| Provider Information | |||||||||
| NPI: | 1285957308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1532 LONE OAK RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705385700 | ||||||||
| FaxNumber: | 2705385701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705385700 | ||||||||
| FaxNumber: | 2705385701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 3006383 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LX0001X | 3006383 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | APN16127 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 6383M | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 3006383 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 7100203570 | 01 | KY | KY MEDICAID | OTHER | 1525514 | 05 | TN | MEDICAID | 3380640 | 01 | TN | GROUP MEDICAID | OTHER | K009831 | 01 | KY | KY MEDICARE PTAN | OTHER | 3380640 | 01 | TN | GROP MEDICARE | OTHER |