Provider Demographics
NPI:1528768926
Name:JOHNSON, JOANNA RENEE (MT)
Entity type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:CREEDE
Mailing Address - State:CO
Mailing Address - Zip Code:81130-0033
Mailing Address - Country:US
Mailing Address - Phone:719-480-2845
Mailing Address - Fax:
Practice Address - Street 1:152 KLONDIKE ROAD
Practice Address - Street 2:
Practice Address - City:CREEDE
Practice Address - State:CO
Practice Address - Zip Code:81130-0033
Practice Address - Country:US
Practice Address - Phone:719-480-2845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0006035172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty