Provider Demographics
NPI:1730321563
Name:JOHNSON, KATHY DEANN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:DEANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:DEANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:14407 215TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6509
Mailing Address - Country:US
Mailing Address - Phone:206-852-0215
Mailing Address - Fax:
Practice Address - Street 1:7415 5TH AVE NE APT 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-5367
Practice Address - Country:US
Practice Address - Phone:206-852-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist