Healthcare Provider Details

I. General information

NPI: 1235018714
Provider Name (Legal Business Name): KASSIDY LYNN JOHNSTON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS KASSIDY LYNN ANDERSON

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E HALL ST
WEBB CITY MO
64870
US

IV. Provider business mailing address

7102 LAWRENCE 1119
MOUNT VERNON MO
65712-6357
US

V. Phone/Fax

Practice location:
  • Phone: 417-673-6080
  • Fax:
Mailing address:
  • Phone: 417-366-4974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2025032215
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: