Provider Demographics
NPI:1447978655
Name:JOHNSON, KELLY MONIQUE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MONIQUE
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 1:3030 5TH ST APT 214
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7712
Mailing Address - Country:US
Mailing Address - Phone:559-412-0879
Mailing Address - Fax:
Practice Address - Street 1:3030 5TH ST APT 214
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-7712
Practice Address - Country:US
Practice Address - Phone:559-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator