Provider Demographics
NPI:1457028086
Name:JOHNSON, KIARRAH TAKIYAH (ATC)
Entity Type:Individual
Prefix:
First Name:KIARRAH
Middle Name:TAKIYAH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S CANARY WAY
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-6208
Mailing Address - Country:US
Mailing Address - Phone:609-204-6599
Mailing Address - Fax:
Practice Address - Street 1:23 S CANARY WAY
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-6208
Practice Address - Country:US
Practice Address - Phone:609-204-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
NJ25MT003236002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program