Provider Demographics
NPI:1114136769
Name:JOHANN, KATHERINE NAN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:NAN
Last Name:JOHANN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21604 66TH AVE W
Mailing Address - Street 2:APARTMENT A
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2100
Mailing Address - Country:US
Mailing Address - Phone:425-780-0399
Mailing Address - Fax:425-672-3675
Practice Address - Street 1:22002 64TH AVE W
Practice Address - Street 2:SUITE M-3
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2528
Practice Address - Country:US
Practice Address - Phone:425-780-0399
Practice Address - Fax:425-672-3675
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004822172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist