Provider Demographics
NPI:1144539107
Name:JOHNSON, KELLY A (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:LARGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8950
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:2 GREAT FALLS PLZ STE 21
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5966
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP101067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily