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NPI Code Detail

MEDICARE: ELLYSE JOHNS PT

MEDICARE:   ELLYSE  JOHNS  PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist2305207547VA

General Provider Information

NPI Number : 1184020828
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLYSE JOHNS PT
Provider Business Mailing Address
First Line : 95 MEDICAL PARK BLVD
Second Line :
City : PETERSBURG
State : VA
Zip : 23805-9280
Country : US
Telephone Number : 804-504-8100
Fax Number : 804-504-7795
Provider Business Practice Location Address
First Line : 95 MEDICAL PARK BLVD
Second Line :
City : PETERSBURG
State : VA
Zip : 23805-9280
Country : US
Telephone Number : 804-504-8100
Fax Number : 804-504-7795
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2014
Last Update Date : 11/07/2014

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