Provider Demographics
NPI:1629666151
Name:JOHNSON VAAL, MIKAELA JOHNSON
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:JOHNSON
Last Name:JOHNSON VAAL
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 1:5585 COCHRAN ST APT 188
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6561
Mailing Address - Country:US
Mailing Address - Phone:719-650-8158
Mailing Address - Fax:
Practice Address - Street 1:5585 COCHRAN ST APT 188
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-6561
Practice Address - Country:US
Practice Address - Phone:719-650-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X, 374J00000X
CA77019225700000X
NY026333225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist