Provider Demographics
NPI:1053826842
Name:JOHNSON, KELLI LAURON (NP-C)
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:LAURON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CHAMBERY DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7651
Mailing Address - Country:US
Mailing Address - Phone:870-224-6307
Mailing Address - Fax:501-615-8818
Practice Address - Street 1:2800 NORTH WILLOW STREET
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114
Practice Address - Country:US
Practice Address - Phone:501-791-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-03
Last Update Date:2017-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF07171423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily