Provider Demographics
NPI:1598288003
Name:JOHNSON, CHARLSEY (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLSEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:CHARLSEY
Other - Middle Name:
Other - Last Name:KESSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4425 WESTPORT PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3240 15TH ST S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6188
Practice Address - Country:US
Practice Address - Phone:701-451-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1058111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP00948558OtherNCMIC