Provider Demographics
NPI:1518204015
Name:RAVEN-JOHNSON, KRISHNA (LMP)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:RAVEN-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 1:423 S BLAKELEY ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2206
Mailing Address - Country:US
Mailing Address - Phone:425-892-4034
Mailing Address - Fax:
Practice Address - Street 1:115 3/4 W MAIN ST STE 213
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1825
Practice Address - Country:US
Practice Address - Phone:425-892-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00007138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist