Provider Demographics
NPI:1417264334
Name:JOHNSON, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:
Other - Last Name:KARNES-JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:733 N POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24515 CEDAR SHORES DR
Practice Address - Street 2:
Practice Address - City:COHASSET
Practice Address - State:MN
Practice Address - Zip Code:55721-8840
Practice Address - Country:US
Practice Address - Phone:218-999-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101876225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist