1396342226 NPI number — KELLY JOHNSON

Table of content: KELLY JOHNSON (NPI 1396342226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396342226 NPI number — KELLY JOHNSON

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396342226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1018
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARIBOU
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04736-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-498-6431
Provider Business Mailing Address Fax Number:
207-492-3181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOULTON
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04730-1877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-532-6523
Provider Business Practice Location Address Fax Number:
207-532-3873
Provider Enumeration Date:
10/05/2020

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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