MEDICARE: MRS. KELLY MARLENE JOHNSON APRN NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	101147	OK

General Provider Information

NPI Number	:	1700345345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MARLENE JOHNSON APRN NP-C

Provider Business Mailing Address
First Line	:	2 UNIVERSITY PLZ STE 204
Second Line	:
City	:	HACKENSACK
State	:	NJ
Zip	:	07601-6211
Country	:	US
Telephone Number	:	551-295-8223
Fax Number	:	405-282-5731

Provider Business Practice Location Address
First Line	:	1320 E OKLAHOMA AVE
Second Line	:
City	:	GUTHRIE
State	:	OK
Zip	:	73044-3757
Country	:	US
Telephone Number	:	405-282-6285
Fax Number	:	405-282-5731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	09/14/2025

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