Provider Demographics
NPI:1336320555
Name:JOHNSON, KELLEY NICOLE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:NICOLE
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 1:4000 E CHARLESTON BLVD
Mailing Address - Street 2:#B230
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6659
Mailing Address - Country:US
Mailing Address - Phone:702-968-4000
Mailing Address - Fax:
Practice Address - Street 1:4455 S PECOS RD STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5029
Practice Address - Country:US
Practice Address - Phone:702-350-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6849-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1336320555Medicaid