Provider Demographics
NPI:1942651039
Name:JOHNSON, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-4855
Mailing Address - Country:US
Mailing Address - Phone:603-582-4700
Mailing Address - Fax:833-413-4978
Practice Address - Street 1:254 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2551
Practice Address - Country:US
Practice Address - Phone:603-582-4700
Practice Address - Fax:833-413-4978
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH059616-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily