Provider Demographics
NPI:1144597659
Name:JOHNSON, DAPHNE S
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:S
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 1:702 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:E401 23RD ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-2203
Practice Address - Country:US
Practice Address - Phone:608-897-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI426-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant