Provider Demographics
NPI:1093055378
Name:JOHNSON, PAMELA ANNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 N WATTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6604
Mailing Address - Country:US
Mailing Address - Phone:503-860-0820
Mailing Address - Fax:
Practice Address - Street 1:8315 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-6707
Practice Address - Country:US
Practice Address - Phone:503-285-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC161389171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist