Provider Demographics
NPI:1447307632
Name:JOHNSON, KELLIE SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:SUZANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 BLETCHLEY AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4599
Mailing Address - Country:US
Mailing Address - Phone:330-497-5975
Mailing Address - Fax:
Practice Address - Street 1:2221 9TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-1464
Practice Address - Country:US
Practice Address - Phone:330-455-3663
Practice Address - Fax:330-455-5355
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063302J208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice