Provider Demographics
NPI:1922662592
Name:JOHNSON, KAITLUND RAKEL (MD)
Entity Type:Individual
Prefix:
First Name:KAITLUND
Middle Name:RAKEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAITLUND
Other - Middle Name:RAKEL
Other - Last Name:TANGVALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:624 E FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2139
Mailing Address - Country:US
Mailing Address - Phone:509-626-9900
Mailing Address - Fax:509-626-9917
Practice Address - Street 1:624 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2139
Practice Address - Country:US
Practice Address - Phone:509-626-9900
Practice Address - Fax:509-626-9917
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61242890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program