Provider Demographics
NPI:1730917162
Name:JOHNSON, SIERRA DANAE
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:DANAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E 12TH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5061
Mailing Address - Country:US
Mailing Address - Phone:620-794-1521
Mailing Address - Fax:
Practice Address - Street 1:612 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD FALLS
Practice Address - State:KS
Practice Address - Zip Code:66845-9798
Practice Address - Country:US
Practice Address - Phone:620-273-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-04205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant