Provider Demographics
NPI:1881643039
Name:JOHNSON, KELLI RENEE (CPM, LM, EMT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPM, LM, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-3642
Mailing Address - Country:US
Mailing Address - Phone:407-699-4207
Mailing Address - Fax:407-699-7897
Practice Address - Street 1:802 FISHER RD
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-3642
Practice Address - Country:US
Practice Address - Phone:407-699-4207
Practice Address - Fax:407-699-7897
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW162176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL744426OtherAETNA PROVIDER NUMBER
FLY041KOtherBCBS PROVIDER NO