Healthcare Provider Details

I. General information

NPI: 1518395326
Provider Name (Legal Business Name): LORA BROOKE JOHNSON ATC, CLT, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2013
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 GREEN MOUNTAIN DR UNIT 306
SOUTH BURLINGTON VT
05403-7965
US

IV. Provider business mailing address

27 GREEN MOUNTAIN DR UNIT 306
SOUTH BURLINGTON VT
05403-7965
US

V. Phone/Fax

Practice location:
  • Phone: 802-249-2909
  • Fax:
Mailing address:
  • Phone: 802-249-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number080302236
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: