Provider Demographics
NPI:1518397017
Name:JOHNSTON, DAVID SHANE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SHANE
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-5204
Mailing Address - Country:US
Mailing Address - Phone:479-968-1198
Mailing Address - Fax:479-967-1178
Practice Address - Street 1:306 E 11TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-6156
Practice Address - Country:US
Practice Address - Phone:479-968-1198
Practice Address - Fax:479-967-1178
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10/11/2013225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist