Provider Demographics
NPI:1891136198
Name:JOHNSON, AMANDA KAY (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 W CHARLESTON BLVD
Mailing Address - Street 2:#270
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5480
Mailing Address - Country:US
Mailing Address - Phone:702-982-2232
Mailing Address - Fax:702-982-2237
Practice Address - Street 1:8751 W CHARLESTON BLVD
Practice Address - Street 2:#270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5480
Practice Address - Country:US
Practice Address - Phone:702-982-2232
Practice Address - Fax:702-982-2237
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST-03590OtherKANSAS LICENSE