Provider Demographics
NPI:1407411861
Name:JOHNSON, KENDRA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39542 GOLDEN LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9405
Mailing Address - Country:US
Mailing Address - Phone:262-719-9072
Mailing Address - Fax:
Practice Address - Street 1:39542 GOLDEN LAKE PARK RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-9405
Practice Address - Country:US
Practice Address - Phone:262-719-9072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer