Provider Demographics
NPI:1700345345
Name:JOHNSON, KELLY MARLENE (APRN NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1095
Mailing Address - Country:US
Mailing Address - Phone:405-282-6285
Mailing Address - Fax:405-282-5731
Practice Address - Street 1:1320 E OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-3757
Practice Address - Country:US
Practice Address - Phone:405-282-6285
Practice Address - Fax:405-282-5731
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101147363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner