Provider Demographics
NPI:1235672023
Name:JOHNSON, KALLI ANN (ATC)
Entity Type:Individual
Prefix:
First Name:KALLI
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KALLI
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:11154 DRAKE ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-7434
Mailing Address - Country:US
Mailing Address - Phone:507-261-1716
Mailing Address - Fax:
Practice Address - Street 1:2515 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5155
Practice Address - Country:US
Practice Address - Phone:507-261-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer