Provider Demographics
NPI:1942458344
Name:JOHNSON, ANITA PEARL (PTA)
Entity Type:Individual
Prefix:MISS
First Name:ANITA
Middle Name:PEARL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6388 BENT OAK LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-6414
Mailing Address - Country:US
Mailing Address - Phone:901-794-3998
Mailing Address - Fax:
Practice Address - Street 1:700 KNUCKOLLS AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008
Practice Address - Country:US
Practice Address - Phone:731-658-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant