Healthcare Provider Details

I. General information

NPI: 1932415254
Provider Name (Legal Business Name): WENDY E JOHNSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY BACON-FULKERSON

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 W IRONWOOD CENTER DR STE B
COEUR D ALENE ID
83814-2606
US

IV. Provider business mailing address

PO BOX 3482
POST FALLS ID
83877-3482
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-1988
  • Fax: 208-765-5654
Mailing address:
  • Phone: 208-209-6170
  • Fax: 208-209-6169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60387980
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3169
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: