Provider Demographics
NPI:1518977388
Name:DUFRESNE, JOHNCY D (MPT)
Entity Type:Individual
Prefix:
First Name:JOHNCY
Middle Name:D
Last Name:DUFRESNE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JOHNCY
Other - Middle Name:D
Other - Last Name:SNEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:101 W 92 HWY
Practice Address - Street 2:STE H
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-7590
Practice Address - Country:US
Practice Address - Phone:816-903-0775
Practice Address - Fax:816-903-0776
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107192225100000X
KS11-02145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA43700035OtherMEDICARE PTAN
33541051OtherBCBS-KC
738395OtherOPTUM
KSKA2868054OtherMEDICARE PTAN