MEDICARE: MRS. ANGIE STALEY JOHNSON MS, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OTR1942	AR

General Provider Information

NPI Number	:	1245498898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGIE STALEY JOHNSON MS, OTR/L

Provider Business Mailing Address
First Line	:	5729 N COUNTRY CLUB BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-4345
Country	:	US
Telephone Number	:	501-663-3351
Fax Number	:

Provider Business Practice Location Address
First Line	:	5729 N COUNTRY CLUB BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-4345
Country	:	US
Telephone Number	:	501-663-3351
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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