Provider Demographics
NPI:1437247731
Name:DAVIS, ANDREA JOHNSON (DPT)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:JOHNSON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MRS
Other - First Name:ANDREA
Other - Middle Name:LYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:639 STOKES RD
Mailing Address - Street 2:STE 103
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-3003
Mailing Address - Country:US
Mailing Address - Phone:609-694-8896
Mailing Address - Fax:609-953-1715
Practice Address - Street 1:320 EVESBORO MEDFORD RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-5733
Practice Address - Country:US
Practice Address - Phone:609-694-8896
Practice Address - Fax:609-953-1715
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00883900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ047692RYMMedicare ID - Type UnspecifiedINDIVIDUAL