=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083814503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANEATRA DANETTE JOHNSON PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2007
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 WILLIAMSBURG LANDING DR
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-8079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-258-2178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 PENNIMAN RD
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-318-1446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306602180
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------