Provider Demographics
NPI:1316377146
Name:JOHNSTON, TALLON MICHEAL
Entity Type:Individual
Prefix:
First Name:TALLON
Middle Name:MICHEAL
Last Name:JOHNSTON
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 1:17901 SE 17TH LN
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1915
Mailing Address - Country:US
Mailing Address - Phone:360-789-3287
Mailing Address - Fax:
Practice Address - Street 1:11600 SE MILL PLAIN BLVD STE 3J
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5083
Practice Address - Country:US
Practice Address - Phone:360-253-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60311704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist