Provider Demographics
NPI:1932290681
Name:JOHNSON, DANA WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:352 W MAPLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2954
Mailing Address - Country:US
Mailing Address - Phone:815-485-9191
Mailing Address - Fax:815-485-2077
Practice Address - Street 1:352 W MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2954
Practice Address - Country:US
Practice Address - Phone:815-485-9191
Practice Address - Fax:815-485-2077
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09915065OtherBLUE CROSS BLUE SHIELD
IL09915065OtherBLUE CROSS BLUE SHIELD