1093935470 NPI number — MS. KELLY RAYHILL JOHNSON OTR

Table of content: MS. KELLY RAYHILL JOHNSON OTR (NPI 1093935470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093935470 NPI number — MS. KELLY RAYHILL JOHNSON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KELLY
Provider Middle Name:
RAYHILL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
KELLY
Provider Other Middle Name:
RAYHILL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093935470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5748 N 2300 LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SALEM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62476-3068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-833-6469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5748 N 2300 LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SALEM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62476-3068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-833-6469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  31004099A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)