Healthcare Provider Details

I. General information

NPI: 1558024117
Provider Name (Legal Business Name): DANIELLE F JOHNSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE F WILES PTA

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N BRYANT AVE
EDMOND OK
73034-6273
US

IV. Provider business mailing address

200 N BRYANT AVE
EDMOND OK
73034-6273
US

V. Phone/Fax

Practice location:
  • Phone: 702-338-9733
  • Fax:
Mailing address:
  • Phone: 702-338-9733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0855
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: