Basic Information
| Provider Information | |||||||||
| NPI: | 1538350061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDRICK | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 461 | ||||||||
| Address2: | |||||||||
| City: | NEVADA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502010461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153823366 | ||||||||
| FaxNumber: | 5153821576 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 8TH ST SW | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500092301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159674124 | ||||||||
| FaxNumber: | 5159679094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 00604 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.