Basic Information
| Provider Information | |||||||||
| NPI: | 1366404360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLIGAN | ||||||||
| OtherFirstName: | SHANNA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7231 SUNWOOD DRIVE NW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RAMSEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128636029 | ||||||||
| FaxNumber: | 6128638942 | ||||||||
| Practice Location | |||||||||
| Address1: | 7231 SUNWOOD DRIVE NW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RAMSEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128636029 | ||||||||
| FaxNumber: | 6128638942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5723 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.