Healthcare Provider Details

I. General information

NPI: 1336480599
Provider Name (Legal Business Name): KELLY ANN JOHNSON A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANN WARD A.T.C.

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 6TH AVE 543
SAN DIEGO CA
92101-6221
US

IV. Provider business mailing address

PO BOX 501473
SAN DIEGO CA
92150-1473
US

V. Phone/Fax

Practice location:
  • Phone: 619-729-6498
  • Fax:
Mailing address:
  • Phone: 619-729-6498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberBOC108324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: