Provider Demographics
NPI:1285386367
Name:JOHNSEN, KELSEY RAE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAE
Last Name:JOHNSEN
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 1:3565 DEL REY ST STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5703
Mailing Address - Country:US
Mailing Address - Phone:732-614-3336
Mailing Address - Fax:
Practice Address - Street 1:3565 DEL REY ST STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5703
Practice Address - Country:US
Practice Address - Phone:732-614-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist