Provider Demographics
NPI:1710733779
Name:JOHNSON, KEARSTEN NICOLE
Entity type:Individual
Prefix:MRS
First Name:KEARSTEN
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KEARSTEN
Other - Middle Name:
Other - Last Name:DAMPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1175 PEACH TREE AVE APT 308
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-3097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 W HUDSON RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-2072
Practice Address - Country:US
Practice Address - Phone:479-936-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist