Provider Demographics
NPI:1871038729
Name:JOHNSON, KELLI SHA'RON (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:SHA'RON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 BORING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-4427
Mailing Address - Country:US
Mailing Address - Phone:678-907-2193
Mailing Address - Fax:
Practice Address - Street 1:3014 BORING RIDGE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4427
Practice Address - Country:US
Practice Address - Phone:678-907-2193
Practice Address - Fax:678-705-5435
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN068141164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse