Provider Demographics
NPI:1871037416
Name:JOHNSON, BRYNN
Entity Type:Individual
Prefix:
First Name:BRYNN
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 1:880 NE HORIZON DR
Mailing Address - Street 2:11-120
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8050
Mailing Address - Country:US
Mailing Address - Phone:815-674-7651
Mailing Address - Fax:
Practice Address - Street 1:2100 DIXON ST
Practice Address - Street 2:SUITE C
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2174
Practice Address - Country:US
Practice Address - Phone:515-265-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083647225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant