Provider Demographics
NPI:1104400985
Name:JOHNSON, MCKENNA
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RANSOM STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743
Mailing Address - Country:US
Mailing Address - Phone:181-455-8731
Mailing Address - Fax:
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT028867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist