MEDICARE: KELLEY NICOLE JOHNSON

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	1041C0700X	Clinical Social Worker	6849-C	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336320555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY NICOLE JOHNSON

Provider Business Mailing Address
First Line	:	4000 E CHARLESTON BLVD
Second Line	:	#B230
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6659
Country	:	US
Telephone Number	:	702-968-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4455 S PECOS RD STE C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5029
Country	:	US
Telephone Number	:	702-350-1430
Fax Number	:

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

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	05/07/2019

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