Provider Demographics
NPI:1851702641
Name:JOHNSON, SHEALA RAE
Entity Type:Individual
Prefix:
First Name:SHEALA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-249-4460
Practice Address - Street 1:3003 TIETON DR STE 230
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3684
Practice Address - Country:US
Practice Address - Phone:509-248-3440
Practice Address - Fax:509-249-4460
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00117204163W00000X
WAAP60468076363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse