Provider Demographics
NPI:1104906635
Name:GARCIA, JOHNNA LYNN (PT)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:LYNN
Last Name:GARCIA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 COULSON AVE
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3947
Mailing Address - Country:US
Mailing Address - Phone:208-819-0439
Mailing Address - Fax:
Practice Address - Street 1:1126 COULSON AVE
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3947
Practice Address - Country:US
Practice Address - Phone:208-819-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1952225100000X
WY1524225100000X
COPTL0011581225100000X
UT8161046-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149982OtherREGENCE BLUE SHIELD
WA0195259OtherWASHINGTON L&I
IDTC241OtherBLUE CROSS
ID807142500Medicaid
IDP00227390OtherRAILROAD MEDICARE
ID1551826Medicare PIN