Provider Demographics
NPI:1487702262
Name:JOHNSON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
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 1:2110 HELM AVE
Mailing Address - Street 2:# 31
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3453
Mailing Address - Country:US
Mailing Address - Phone:559-292-1430
Mailing Address - Fax:
Practice Address - Street 1:205 N BLACKSTONE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-1914
Practice Address - Country:US
Practice Address - Phone:559-498-0241
Practice Address - Fax:559-498-6220
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner