Provider Demographics
NPI:1568721504
Name:NAILLIEUX-JOHNSON, KEZIA G (PT)
Entity Type:Individual
Prefix:
First Name:KEZIA
Middle Name:G
Last Name:NAILLIEUX-JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KEZIA
Other - Middle Name:G
Other - Last Name:NAILLIEUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3603 S MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-5615
Mailing Address - Country:US
Mailing Address - Phone:206-535-7356
Mailing Address - Fax:206-466-1527
Practice Address - Street 1:2201 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-7020
Practice Address - Country:US
Practice Address - Phone:206-535-7356
Practice Address - Fax:206-466-1527
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010829A225100000X
WAPT60585779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01490671OtherRR MEDICARE
INP01490671OtherRR MEDICARE