Provider Demographics
NPI:1780182584
Name:JOHNSON, ROBERTA LYNN (LPN)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BOBBIE
Other - Middle Name:
Other - Last Name:STACEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8634 QUINAULT DR NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5826
Mailing Address - Country:US
Mailing Address - Phone:360-789-5261
Mailing Address - Fax:
Practice Address - Street 1:INTREPID SPIRIT CENTER 90390 GARDNER LOOP
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-9017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALPN00047974164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse