Provider Demographics
NPI:1689797268
Name:JOHNSTON, KELLI ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 BLUEBIRD RD OFC 7
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-8308
Mailing Address - Country:US
Mailing Address - Phone:843-894-3490
Mailing Address - Fax:
Practice Address - Street 1:1834 BLUEBIRD RD
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-8308
Practice Address - Country:US
Practice Address - Phone:843-894-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009270Medicaid