Provider Demographics
NPI:1073982179
Name:JOHNSON, KELLE B (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:32-36 CENTRAL AVE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1840
Mailing Address - Country:US
Mailing Address - Phone:570-723-0104
Mailing Address - Fax:570-723-0118
Practice Address - Street 1:32-36 CENTRAL AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1840
Practice Address - Country:US
Practice Address - Phone:570-723-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant