Provider Demographics
NPI:1083831317
Name:JOHNSON, PATRICIA E (MA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3543
Mailing Address - Country:US
Mailing Address - Phone:307-856-3847
Mailing Address - Fax:307-856-7484
Practice Address - Street 1:218 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3543
Practice Address - Country:US
Practice Address - Phone:307-856-3847
Practice Address - Fax:307-856-7484
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY103237600000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112093000Medicaid