Basic Information
| Provider Information | |||||||||
| NPI: | 1154817641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TAMMIE | ||||||||
| MiddleName: | KELLER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT, MS, ATP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | TAMMIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 255 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095967733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 255 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146423687 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2018 | ||||||||
| LastUpdateDate: | 07/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No ID Information.