Provider Demographics
NPI:1174174668
Name:JOHNSON, KATIE ROSE (RN-BSN)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN-BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 NE 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6282
Mailing Address - Country:US
Mailing Address - Phone:360-719-8368
Mailing Address - Fax:
Practice Address - Street 1:5411 E MILL PLAIN BLVD STE 28
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7046
Practice Address - Country:US
Practice Address - Phone:360-852-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60654273163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice