Provider Demographics
NPI:1033768544
Name:JOHNSON, ABIGAIL MARTINA (ATC)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:MARTINA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:MARTINA
Other - Last Name:DEWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15368 STACIE CT
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-9424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9622 256TH ST N
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:IL
Practice Address - Zip Code:61275-9054
Practice Address - Country:US
Practice Address - Phone:309-523-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer