Provider Demographics
NPI:1225298797
Name:JOHNSON, ALICIA KATHERINE (LMP,)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:KATHERINE
Last Name:JOHNSON
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 1:1207 SE RASMUSSEN BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-8618
Mailing Address - Country:US
Mailing Address - Phone:360-607-7368
Mailing Address - Fax:
Practice Address - Street 1:1207 SE RASMUSSEN BLVD STE 111
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-8618
Practice Address - Country:US
Practice Address - Phone:360-607-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024163305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service