Provider Demographics
NPI:1346399862
Name:JOHNSON, MISTY MARIE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:MARIE
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 1:747 WASHINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-2917
Mailing Address - Country:US
Mailing Address - Phone:253-854-3938
Mailing Address - Fax:253-854-0430
Practice Address - Street 1:747 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-2917
Practice Address - Country:US
Practice Address - Phone:253-854-3938
Practice Address - Fax:253-854-0430
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017116225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist