Provider Demographics
NPI:1629240494
Name:JOHNSON, CONNIE
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 S QUENTIN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-2260
Mailing Address - Country:US
Mailing Address - Phone:919-781-9565
Mailing Address - Fax:
Practice Address - Street 1:3724 NATIONAL DR
Practice Address - Street 2:SUITE 110
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4070
Practice Address - Country:US
Practice Address - Phone:919-781-9965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3971225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant