Basic Information
| Provider Information | |||||||||
| NPI: | 1558665414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W 72ND ST | ||||||||
| Address2: | APT 1D | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100232661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319445923 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 BELLE TERRE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740008 | ||||||||
| FaxNumber: | 6314740224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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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 | 363A00000X | 014438 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 113422995 | 01 | NY | TAX ID # | OTHER |