Provider Demographics
NPI:1174646772
Name:JOHNSTAD, DON
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:
Last Name:JOHNSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:WILSON CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98860-0044
Mailing Address - Country:US
Mailing Address - Phone:509-246-1660
Mailing Address - Fax:
Practice Address - Street 1:318 MAIN AVE
Practice Address - Street 2:
Practice Address - City:SOAP LAKE
Practice Address - State:WA
Practice Address - Zip Code:98851
Practice Address - Country:US
Practice Address - Phone:509-246-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist