Provider Demographics
NPI:1447857057
Name:JOHNSON, MAKAILA DAWN (DPT)
Entity type:Individual
Prefix:
First Name:MAKAILA
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MAKAILA
Other - Middle Name:DAWN
Other - Last Name:BINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3061 N SUNNY SIDE PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-2789
Mailing Address - Country:US
Mailing Address - Phone:208-921-0403
Mailing Address - Fax:
Practice Address - Street 1:3330 E LOUISE DR STE 400
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5123
Practice Address - Country:US
Practice Address - Phone:208-381-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist