Healthcare Provider Details

I. General information

NPI: 1881377034
Provider Name (Legal Business Name): KELLY JOHANSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MARYVILLE UNIVERSITY DR
SAINT LOUIS MO
63141-5849
US

IV. Provider business mailing address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

V. Phone/Fax

Practice location:
  • Phone: 800-627-9855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: