Provider Demographics
NPI:1346548765
Name:JOHNSON, ANITA ANN (MT)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6468
Mailing Address - Country:US
Mailing Address - Phone:208-523-0121
Mailing Address - Fax:
Practice Address - Street 1:1880 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6468
Practice Address - Country:US
Practice Address - Phone:208-523-0121
Practice Address - Fax:208-529-0001
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist