Provider Demographics
NPI:1780439422
Name:JOHNSON, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
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 1:11 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-2199
Mailing Address - Country:US
Mailing Address - Phone:513-818-5285
Mailing Address - Fax:
Practice Address - Street 1:1381 W OHIO PIKE APT 4F
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1348
Practice Address - Country:US
Practice Address - Phone:513-331-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide