Provider Demographics
NPI:1336480599
Name:JOHNSON, KELLY ANN (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 501473
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-1473
Mailing Address - Country:US
Mailing Address - Phone:619-729-6498
Mailing Address - Fax:
Practice Address - Street 1:950 6TH AVE
Practice Address - Street 2:543
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6221
Practice Address - Country:US
Practice Address - Phone:619-729-6498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOC108324174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator