Provider Demographics
NPI:1407308935
Name:JOHNSON, CALYN NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:CALYN
Middle Name:NICOLE
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 1:14425 N 2320 RD
Mailing Address - Street 2:
Mailing Address - City:GOTEBO
Mailing Address - State:OK
Mailing Address - Zip Code:73041-6708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:580-379-5820
Practice Address - Fax:580-379-5829
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2667225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201092420AMedicaid