Healthcare Provider Details

I. General information

NPI: 1326590795
Provider Name (Legal Business Name): DANIELLE JOHNSTON MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TENNY LN
CORNWALL NY
12518-1914
US

IV. Provider business mailing address

6 TENNY LN
CORNWALL NY
12518-1914
US

V. Phone/Fax

Practice location:
  • Phone: 845-641-2035
  • Fax:
Mailing address:
  • Phone: 845-641-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002495
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: