Provider Demographics
NPI:1013010727
Name:JOHNSON, NYLIN J (PT)
Entity Type:Individual
Prefix:
First Name:NYLIN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:1188 SPORTSPLEX DR
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-9591
Practice Address - Country:US
Practice Address - Phone:801-547-1155
Practice Address - Fax:801-547-1173
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1184062401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTN0793Medicaid