Provider Demographics
NPI:1659996585
Name:JOHNSON, SUELLEN CAROLINE CRUZ
Entity Type:Individual
Prefix:MRS
First Name:SUELLEN
Middle Name:CAROLINE CRUZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUELLEN
Other - Middle Name:CAROLINE MARQUES
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 E 77TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1939
Mailing Address - Country:US
Mailing Address - Phone:816-313-9985
Mailing Address - Fax:
Practice Address - Street 1:1120 E 77TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1939
Practice Address - Country:US
Practice Address - Phone:816-313-9985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014754261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy