Healthcare Provider Details

I. General information

NPI: 1376893263
Provider Name (Legal Business Name): TIFFANY J JOHNSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 AURORA DR
SUMMIT WI
53066-4899
US

IV. Provider business mailing address

N3117 SCHMIDT RD
JEFFERSON WI
53549-9741
US

V. Phone/Fax

Practice location:
  • Phone: 262-434-2600
  • Fax:
Mailing address:
  • Phone: 920-285-4475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: