Provider Demographics
NPI:1417190802
Name:JOHNSON, KEWN
Entity Type:Individual
Prefix:
First Name:KEWN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
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 591
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0022
Mailing Address - Country:US
Mailing Address - Phone:425-888-0670
Mailing Address - Fax:
Practice Address - Street 1:219 CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045-8262
Practice Address - Country:US
Practice Address - Phone:425-888-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPI 60031545225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant