Provider Demographics
NPI:1861160632
Name:JOHNSON, KATLYNN ROSE
Entity type:Individual
Prefix:
First Name:KATLYNN
Middle Name:ROSE
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 1:1301 W 6TH ST APT 3305
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-3184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3701 N 132ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-1849
Practice Address - Country:US
Practice Address - Phone:402-431-0655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17256183500000X
IA24235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist