Healthcare Provider Details

I. General information

NPI: 1851643423
Provider Name (Legal Business Name): KELLI ALMARIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WEST 75TH STREET
SHAWNEE MISSION KS
66204
US

IV. Provider business mailing address

3710 NW LAKE DR
LEES SUMMIT MO
64064-3020
US

V. Phone/Fax

Practice location:
  • Phone: 913-362-1669
  • Fax:
Mailing address:
  • Phone: 816-478-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number001791
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: