Provider Demographics
NPI:1326180076
Name:JOHNSON, TAMMY L (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 COMMERCE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3738
Mailing Address - Country:US
Mailing Address - Phone:360-425-4647
Mailing Address - Fax:360-578-2496
Practice Address - Street 1:1339 COMMERCE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3738
Practice Address - Country:US
Practice Address - Phone:360-425-4647
Practice Address - Fax:360-578-2496
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO1822156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
212744Other212744
LO22314Other22314
WA0851Other0851
WA2026979Medicaid
4590180001Medicare ID - Type Unspecified