Healthcare Provider Details

I. General information

NPI: 1245582527
Provider Name (Legal Business Name): KELLY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10385 COMMERCE DR SUITE22
CARMEL IN
46032-7630
US

IV. Provider business mailing address

3528 ALPINE PL
INDIANAPOLIS IN
46226-6441
US

V. Phone/Fax

Practice location:
  • Phone: 317-660-1342
  • Fax:
Mailing address:
  • Phone: 317-918-9043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20902165
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: