Provider Demographics
NPI:1346069648
Name:JOHNSON, KIERSTON ALEXIS (MS, LAT, ATC)
Entity type:Individual
Prefix:MISS
First Name:KIERSTON
Middle Name:ALEXIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 MALAGA RD
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-4114
Mailing Address - Country:US
Mailing Address - Phone:609-892-6615
Mailing Address - Fax:
Practice Address - Street 1:1875 MALAGA RD
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330-4114
Practice Address - Country:US
Practice Address - Phone:609-892-6615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003318002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer