Provider Demographics
NPI:1346697489
Name:JOHNSON, ASHLEY (LA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 NW CIRCLE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1485
Mailing Address - Country:US
Mailing Address - Phone:541-768-4370
Mailing Address - Fax:541-768-9790
Practice Address - Street 1:996 NW CIRCLE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1485
Practice Address - Country:US
Practice Address - Phone:541-768-4370
Practice Address - Fax:541-768-9790
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCOS- FT- 10119169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist