Provider Demographics
NPI:1730954181
Name:JOHNSON, KYLE GREGORY (APRN FNP-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:GREGORY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1501
Mailing Address - Country:US
Mailing Address - Phone:812-480-9469
Mailing Address - Fax:
Practice Address - Street 1:1232 FOX HOLLOW CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4614
Practice Address - Country:US
Practice Address - Phone:812-480-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4011302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily