Provider Demographics
NPI:1942240692
Name:JOHNSON, DANA ELLYN (DPT)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:ELLYN
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 1:2400 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-6964
Mailing Address - Country:US
Mailing Address - Phone:715-255-2772
Mailing Address - Fax:
Practice Address - Street 1:2400 47TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-6964
Practice Address - Country:US
Practice Address - Phone:715-255-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA021202251P0200X
IL070-0180702251P0200X
WI11006-242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0129630OtherCIGNA
IAF232191OtherMIDLANDS CHOICE
IA16843OtherWELLMARK