Provider Demographics
NPI:1699011767
Name:JOHNSON, MARISA PROTASEL (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:PROTASEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:SAYLER
Other - Last Name:PROTASEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60200108163W00000X
WAAP61312604363L00000X
IL209.021409363LP0808X
OR202208550NP-PP363LP0808X
OR202208453RN163W00000X
IL041495198163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500819896Medicaid