Healthcare Provider Details

I. General information

NPI: 1871037416
Provider Name (Legal Business Name): BRYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 DIXON ST SUITE C
DES MOINES IA
50316-2174
US

IV. Provider business mailing address

880 NE HORIZON DR 11-120
WAUKEE IA
50263-8050
US

V. Phone/Fax

Practice location:
  • Phone: 515-265-1020
  • Fax:
Mailing address:
  • Phone: 815-674-7651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number083647
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: