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NPI Code Detail

MEDICARE: KELLY LYNN JOHNSON

MEDICARE: KELLY LYNN 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1912491390
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY LYNN JOHNSON
Provider Business Mailing Address
First Line : 9327 N EVANSVILLE BROOKLYN RD
Second Line :
City : EVANSVILLE
State : WI
Zip : 53536-9241
Country : US
Telephone Number : 608-699-2699
Fax Number :
Provider Business Practice Location Address
First Line : 559 ZOR SHRINE PL
Second Line :
City : MADISON
State : WI
Zip : 53719-2068
Country : US
Telephone Number : 608-833-0123
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/19/2018
Last Update Date : 06/19/2018

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