Basic Information
Provider Information | |||||||||
NPI: | 1861990228 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | MONICA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 784 HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | FRENCHBURG | ||||||||
State: | KY | ||||||||
PostalCode: | 403228123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067689190 | ||||||||
FaxNumber: | 6067689180 | ||||||||
Practice Location | |||||||||
Address1: | 125 FOXGLOVE DR STE D | ||||||||
Address2: |   | ||||||||
City: | MT STERLING | ||||||||
State: | KY | ||||||||
PostalCode: | 403539735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8594983333 | ||||||||
FaxNumber: | 8594983332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2018 | ||||||||
LastUpdateDate: | 02/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011481 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | MJ5721990 | 01 | KY | KY DEA | OTHER | 3011481 | 01 | KY | KY APRN LICENSE | OTHER |