Provider Demographics
NPI:1396975553
Name:JOHNSON, KELLIE NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S 48TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1283
Mailing Address - Country:US
Mailing Address - Phone:402-483-3333
Mailing Address - Fax:402-483-3297
Practice Address - Street 1:1600 S 48TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1283
Practice Address - Country:US
Practice Address - Phone:402-483-3333
Practice Address - Fax:402-483-3297
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1845363L00000X
NE111063363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1845 TEMPOtherAPRN LICENSE
NE63153OtherRN LICENSE
NE111063OtherAPRN LICENSE
NE47084496100Medicaid
NE099106003Medicare PIN