Provider Demographics
NPI:1730072646
Name:JOHNSON, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5602 CYPRESS CREEK DR APT 201
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3505
Mailing Address - Country:US
Mailing Address - Phone:843-300-8946
Mailing Address - Fax:
Practice Address - Street 1:2918 MINNESOTA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1127
Practice Address - Country:US
Practice Address - Phone:843-300-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator