Healthcare Provider Details

I. General information

NPI: 1033768544
Provider Name (Legal Business Name): ABIGAIL MARTINA JOHNSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL MARTINA DEWITT

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9622 256TH ST N
PORT BYRON IL
61275-9054
US

IV. Provider business mailing address

15368 STACIE CT
DUBUQUE IA
52002-9424
US

V. Phone/Fax

Practice location:
  • Phone: 309-523-3184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: