Provider Demographics
NPI:1578654653
Name:JOHNSON, KELLI SHANNON (OD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:SHANNON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N ANDERSON LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-6926
Mailing Address - Country:US
Mailing Address - Phone:615-826-7658
Mailing Address - Fax:
Practice Address - Street 1:204 N ANDERSON LN
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-6926
Practice Address - Country:US
Practice Address - Phone:615-826-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU85679Medicare UPIN