Provider Demographics
NPI:1831399385
Name:JOHNSON-MCKISSICK, COURTNEY DAWN (DPM)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:DAWN
Last Name:JOHNSON-MCKISSICK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-4200
Mailing Address - Fax:814-375-4232
Practice Address - Street 1:820 TURNPIKE AVE
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-1233
Practice Address - Country:US
Practice Address - Phone:814-765-2006
Practice Address - Fax:814-765-5736
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005951213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023372050001Medicaid
PA2106984OtherHIGHMARK BCBS
PA162123Medicare PIN