Provider Demographics
NPI:1326748245
Name:JOHNSON, MADALYNN BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:MADALYNN
Middle Name:BROOKE
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 1:3780 E DENTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5904
Mailing Address - Country:US
Mailing Address - Phone:414-731-6369
Mailing Address - Fax:
Practice Address - Street 1:6735 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3325
Practice Address - Country:US
Practice Address - Phone:414-354-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4048-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant