Provider Demographics
NPI:1992034144
Name:JOHNSON, MALLORY MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13031 123RD LN NE
Mailing Address - Street 2:D202
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7344
Mailing Address - Country:US
Mailing Address - Phone:206-714-4355
Mailing Address - Fax:
Practice Address - Street 1:670 NW GILMAN BLVD
Practice Address - Street 2:SUITE #B2
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2444
Practice Address - Country:US
Practice Address - Phone:425-427-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60119122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist