Provider Demographics
NPI:1508072372
Name:JOHNSON, ANDREA JOELLEN I (PTA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:JOELLEN
Last Name:JOHNSON
Suffix:I
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 WB HOLW
Mailing Address - Street 2:
Mailing Address - City:JENKINS
Mailing Address - State:KY
Mailing Address - Zip Code:41537-9147
Mailing Address - Country:US
Mailing Address - Phone:606-633-3554
Mailing Address - Fax:606-633-3627
Practice Address - Street 1:457 BENTLEY LOOP
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537-9004
Practice Address - Country:US
Practice Address - Phone:606-832-1471
Practice Address - Fax:606-832-0397
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01754225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant