Provider Demographics
NPI:1023824661
Name:JOHNSON, KELLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:KAUFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19408 STERLING HILL LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-6587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25381 RAILROAD CANYON RD
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2705
Practice Address - Country:US
Practice Address - Phone:951-244-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist