Provider Demographics
NPI:1932415254
Name:JOHNSON, WENDY E (DPT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:BACON-FULKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3482
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-3482
Mailing Address - Country:US
Mailing Address - Phone:208-209-6170
Mailing Address - Fax:208-209-6169
Practice Address - Street 1:2170 W IRONWOOD CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2606
Practice Address - Country:US
Practice Address - Phone:208-667-1988
Practice Address - Fax:208-765-5654
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60387980225100000X
IDPT3169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist