Provider Demographics
NPI:1942964002
Name:JOHNSON, KAELIN DANAE (PTA)
Entity Type:Individual
Prefix:
First Name:KAELIN
Middle Name:DANAE
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 1:11726 SE 1040TH AVE
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-6024
Mailing Address - Country:US
Mailing Address - Phone:918-448-6622
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2930225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant