Provider Demographics
NPI:1083814503
Name:JOHNSON, LANEATRA DANETTE (PTA)
Entity Type:Individual
Prefix:
First Name:LANEATRA
Middle Name:DANETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 PENNIMAN RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5416
Mailing Address - Country:US
Mailing Address - Phone:757-318-1446
Mailing Address - Fax:
Practice Address - Street 1:5500 WILLIAMSBURG LANDING DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-8079
Practice Address - Country:US
Practice Address - Phone:757-258-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602180225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant