Provider Demographics
NPI:1255774501
Name:JOHNSON, KELSEY
Entity type:Individual
Prefix:MS
First Name:KELSEY
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 1:11143 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 311
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1727
Mailing Address - Country:US
Mailing Address - Phone:260-482-3886
Mailing Address - Fax:
Practice Address - Street 1:11143 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 311
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1727
Practice Address - Country:US
Practice Address - Phone:260-482-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99052419A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS