Provider Demographics
NPI:1851930119
Name:JOHNSON, TAMARA C (MST)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MST
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:C
Other - Last Name:CLOUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MST
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2641 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4240
Practice Address - Country:US
Practice Address - Phone:920-964-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3846-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist