Provider Demographics
NPI:1265483044
Name:JOHNSON, LISA MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2979 SQUALICUM PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1813
Mailing Address - Country:US
Mailing Address - Phone:360-734-2700
Mailing Address - Fax:360-734-8362
Practice Address - Street 1:2979 SQUALICUM PKWY
Practice Address - Street 2:STE 101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1813
Practice Address - Country:US
Practice Address - Phone:360-734-2700
Practice Address - Fax:360-734-8362
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8857595Medicare PIN
WAP08238Medicare UPIN
WAG8857595Medicare PIN