Provider Demographics
NPI:1043053648
Name:JOHNSON, KENNEDI LISA GABRIELLE
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:LISA GABRIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2590 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-5843
Mailing Address - Country:US
Mailing Address - Phone:985-313-1093
Mailing Address - Fax:985-313-1092
Practice Address - Street 1:2590 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5843
Practice Address - Country:US
Practice Address - Phone:985-313-1093
Practice Address - Fax:985-313-1092
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator