Provider Demographics
NPI:1437150059
Name:JOHNSON, LYNN R (PT; LAT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT; LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-571-6739
Mailing Address - Fax:208-452-0019
Practice Address - Street 1:1611 N WHITLEY DR STE 1A
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2180
Practice Address - Country:US
Practice Address - Phone:208-452-0021
Practice Address - Fax:208-452-0019
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2013-03-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IDPT178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010025680OtherBLUE SHIELD PIN
IDT4884OtherBLUE CROSS PIN
ID000010025680OtherBLUE SHIELD PIN
ID1378511Medicare ID - Type UnspecifiedGROUP ID