Provider Demographics
NPI:1851793608
Name:JOHNSON, CHELLSIE D (MED, ATC)
Entity Type:Individual
Prefix:
First Name:CHELLSIE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 CHAPARRAL
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-5432
Mailing Address - Country:US
Mailing Address - Phone:970-381-3472
Mailing Address - Fax:
Practice Address - Street 1:3500 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3125
Practice Address - Country:US
Practice Address - Phone:307-253-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer