Provider Demographics
NPI:1386127041
Name:JOHNSON, KETTY
Entity type:Individual
Prefix:
First Name:KETTY
Middle Name:
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 1:1016 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4520
Mailing Address - Country:US
Mailing Address - Phone:704-807-5699
Mailing Address - Fax:704-631-4574
Practice Address - Street 1:1016 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4520
Practice Address - Country:US
Practice Address - Phone:704-807-5699
Practice Address - Fax:704-631-4574
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator