Healthcare Provider Details

I. General information

NPI: 1730917162
Provider Name (Legal Business Name): SIERRA DANAE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N WALNUT ST
COTTONWOOD FALLS KS
66845-9798
US

IV. Provider business mailing address

302 E 12TH AVE APT 5
EMPORIA KS
66801-5061
US

V. Phone/Fax

Practice location:
  • Phone: 620-273-6369
  • Fax:
Mailing address:
  • Phone: 620-794-1521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-04205
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: