Provider Demographics
NPI:1225447113
Name:JOHNSON, ABBY (LAT)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16650 WEST 78TH STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346
Mailing Address - Country:US
Mailing Address - Phone:952-873-7400
Mailing Address - Fax:
Practice Address - Street 1:16550 W 78TH STREET
Practice Address - Street 2:SUITE B
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346
Practice Address - Country:US
Practice Address - Phone:952-873-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1509-392255A2300X
MN27412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer