Provider Demographics
NPI:1992406508
Name:JOHNSON, NATASHA LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 WORKS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:ME
Mailing Address - Zip Code:04921-3212
Mailing Address - Country:US
Mailing Address - Phone:207-570-6130
Mailing Address - Fax:
Practice Address - Street 1:758 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3224
Practice Address - Country:US
Practice Address - Phone:207-941-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA3954225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant