Provider Demographics
NPI:1558024117
Name:JOHNSON, DANIELLE F (PTA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:F
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:F
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:200 N BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6273
Mailing Address - Country:US
Mailing Address - Phone:702-338-9733
Mailing Address - Fax:
Practice Address - Street 1:200 N BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6273
Practice Address - Country:US
Practice Address - Phone:702-338-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0855225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant