Provider Demographics
NPI:1821027194
Name:JOHNSON, LYNNETTE YVONNE (ATC)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:YVONNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 OLD LAKE CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8152
Mailing Address - Country:US
Mailing Address - Phone:662-236-2368
Mailing Address - Fax:
Practice Address - Street 1:1 COLISUEM DRIVE
Practice Address - Street 2:GILLOM SPORTS CENTER
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7303
Practice Address - Fax:662-915-5648
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT00182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer