Provider Demographics
NPI:1619714466
Name:JOHNSON, KOLU LEELEE
Entity type:Individual
Prefix:
First Name:KOLU
Middle Name:LEELEE
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 1:10702 RIDGE ACRES RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8204
Mailing Address - Country:US
Mailing Address - Phone:704-281-7130
Mailing Address - Fax:
Practice Address - Street 1:6608 E W T HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5127
Practice Address - Country:US
Practice Address - Phone:704-900-7761
Practice Address - Fax:833-948-3597
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024001913363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care