Provider Demographics
NPI:1437460508
Name:JOHNSON, LISA DIANE (LMT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:RECKNAGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:73-4536 OLD MAMALAHOA HWY
Mailing Address - Street 2:UNIT A
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-8632
Mailing Address - Country:US
Mailing Address - Phone:808-089-5136
Mailing Address - Fax:
Practice Address - Street 1:77-6425 KUAKINI HWY
Practice Address - Street 2:SUITE D103
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3213
Practice Address - Country:US
Practice Address - Phone:808-937-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT - 4487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist