Provider Demographics
NPI:1780676726
Name:JOHNSON, DANA ILENE (LMP, MMP)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:ILENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25506 157TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4161
Mailing Address - Country:US
Mailing Address - Phone:253-435-1285
Mailing Address - Fax:253-445-8632
Practice Address - Street 1:11803 101ST AVE CT E
Practice Address - Street 2:STE 100
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3473
Practice Address - Country:US
Practice Address - Phone:253-435-1285
Practice Address - Fax:253-445-8632
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014833225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195842OtherL AND I
1880J0OtherREGENCE