Provider Demographics
NPI:1609942283
Name:JOHANSEN, KATHRYN LEILA DRAKE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:LEILA DRAKE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12916 86TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5453
Mailing Address - Country:US
Mailing Address - Phone:253-840-3593
Mailing Address - Fax:
Practice Address - Street 1:920 ALDER AVE
Practice Address - Street 2:#203
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1401
Practice Address - Country:US
Practice Address - Phone:253-826-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007575363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health