Provider Demographics
NPI:1740557289
Name:JOHNSON, STEPHANIE R (CRNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:MACTAVISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8201 164TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-7615
Mailing Address - Country:US
Mailing Address - Phone:425-818-5311
Mailing Address - Fax:425-434-1755
Practice Address - Street 1:8201 164TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-7615
Practice Address - Country:US
Practice Address - Phone:425-818-5311
Practice Address - Fax:425-434-1755
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60474118363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health