Provider Demographics
NPI:1427410281
Name:JOHNSON, KELLY ROSE
Entity type:Individual
Prefix:
First Name:KELLY
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 1:206 BROOKSITE DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4443
Mailing Address - Country:US
Mailing Address - Phone:845-656-4818
Mailing Address - Fax:
Practice Address - Street 1:1521 JARRET PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2606
Practice Address - Country:US
Practice Address - Phone:718-862-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT017016208600000X
390200000X
NY310107-01208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program