Provider Demographics
NPI:1417128810
Name:JOHNSON, LAVONNE FERN (MASSAGE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:FERN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48698
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99228
Mailing Address - Country:US
Mailing Address - Phone:509-218-3043
Mailing Address - Fax:
Practice Address - Street 1:524 SOUTH UNIVERSITY
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99206
Practice Address - Country:US
Practice Address - Phone:509-218-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist