Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1730729344 |
---|---|
Provider Name | Mia Johnson |
First Address | Stockton, CA 95206-4958 |
Second Address | Tracy, CA 95377-8909 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2020 |
Last Update Date | 11/01/2020 |