Provider Demographics
NPI:1538105267
Name:JOHNSON, KELLEY L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:L
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1515 RIVER PL STE 100
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5610
Practice Address - Country:US
Practice Address - Phone:770-848-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN253424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP16358Medicare UPIN
AL000095295Medicare ID - Type Unspecified