Provider Demographics
NPI:1669134565
Name:JOHNSON, WAKENDA ELIZABETH (OT)
Entity type:Individual
Prefix:
First Name:WAKENDA
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GLEN COVE MARINA RD E
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7287
Mailing Address - Country:US
Mailing Address - Phone:707-287-2615
Mailing Address - Fax:
Practice Address - Street 1:901 SPYGLASS PKWY
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-6921
Practice Address - Country:US
Practice Address - Phone:510-221-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist