Provider Demographics
NPI:1760191886
Name:JOHNSON, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 N MAIN ST APT 309
Mailing Address - Street 2:
Mailing Address - City:MUNROE FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44262-1061
Mailing Address - Country:US
Mailing Address - Phone:234-380-0048
Mailing Address - Fax:
Practice Address - Street 1:379 N MAIN ST APT 309
Practice Address - Street 2:
Practice Address - City:MUNROE FALLS
Practice Address - State:OH
Practice Address - Zip Code:44262-1061
Practice Address - Country:US
Practice Address - Phone:234-380-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No347C00000XTransportation ServicesPrivate Vehicle