Provider Demographics
NPI:1992190011
Name:JOHNSTON, KIRSTEN (PTA)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:JOHNSTON
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 1:206 HOSPITAL LN
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1276
Mailing Address - Country:US
Mailing Address - Phone:573-768-3349
Mailing Address - Fax:
Practice Address - Street 1:206 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1276
Practice Address - Country:US
Practice Address - Phone:573-768-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002049225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant