Provider Demographics
NPI:1417529272
Name:JOHNSON, KELLY LYNN (CPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:LYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4930 DAISY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6797
Mailing Address - Country:US
Mailing Address - Phone:541-912-2563
Mailing Address - Fax:
Practice Address - Street 1:2130 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2592
Practice Address - Country:US
Practice Address - Phone:541-747-3362
Practice Address - Fax:541-741-2287
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-002894183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician