Provider Demographics
NPI:1013565183
Name:JOHNSON, CAROLYN LEE (ARNP, CNM)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12238 KOEPPEN RD SE
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-9641
Mailing Address - Country:US
Mailing Address - Phone:253-973-8744
Mailing Address - Fax:
Practice Address - Street 1:106 PLAZA DR SE BLDG C1
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8841
Practice Address - Country:US
Practice Address - Phone:253-370-6987
Practice Address - Fax:253-248-0671
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61580533367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty