Provider Demographics
NPI:1851721773
Name:STEWART-JOHNSON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:STEWART-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 1:1129 KENNEBEC ST
Mailing Address - Street 2:APT 2E
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3342
Mailing Address - Country:US
Mailing Address - Phone:301-466-1350
Mailing Address - Fax:
Practice Address - Street 1:8926 WOODYARD RD
Practice Address - Street 2:701
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4220
Practice Address - Country:US
Practice Address - Phone:301-856-1682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3843225200000X
VA2306602643225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant