Provider Demographics
NPI:1669915880
Name:JOHNSON, TIFFANY (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LANCASTER AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3310
Mailing Address - Country:US
Mailing Address - Phone:302-373-2458
Mailing Address - Fax:
Practice Address - Street 1:2601 RIVER RD
Practice Address - Street 2:
Practice Address - City:CONESTOGA
Practice Address - State:PA
Practice Address - Zip Code:17516-9327
Practice Address - Country:US
Practice Address - Phone:717-842-2321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-19
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT75922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer