Provider Demographics
NPI:1184253304
Name:JOHNSON, AMANDA SUE (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
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 1:915 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2193
Mailing Address - Country:US
Mailing Address - Phone:218-249-5439
Mailing Address - Fax:
Practice Address - Street 1:915 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2193
Practice Address - Country:US
Practice Address - Phone:218-249-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist