Provider Demographics
NPI:1639382856
Name:JOHNSON, WENDY DAWN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 BREAM POND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32409-4603
Mailing Address - Country:US
Mailing Address - Phone:850-527-3695
Mailing Address - Fax:850-785-2845
Practice Address - Street 1:216 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4915
Practice Address - Country:US
Practice Address - Phone:850-527-3695
Practice Address - Fax:850-785-2845
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA49990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist