Provider Demographics
NPI:1245582527
Name:JOHNSON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 ALPINE PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-6441
Mailing Address - Country:US
Mailing Address - Phone:317-918-9043
Mailing Address - Fax:
Practice Address - Street 1:10385 COMMERCE DR
Practice Address - Street 2:SUITE22
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7630
Practice Address - Country:US
Practice Address - Phone:317-660-1342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20902165225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist