Provider Demographics
NPI:1972567071
Name:JOHNSON, KELLY S (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31113
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-1113
Mailing Address - Country:US
Mailing Address - Phone:206-632-2023
Mailing Address - Fax:
Practice Address - Street 1:1914 N 34TH ST
Practice Address - Street 2:STE. 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-9058
Practice Address - Country:US
Practice Address - Phone:206-632-2023
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034297111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8851637Medicare ID - Type Unspecified