Provider Demographics
NPI:1336576396
Name:KATHRYN L DRAKE JOHANSEN ARNP, PLLC
Entity Type:Organization
Organization Name:KATHRYN L DRAKE JOHANSEN ARNP, PLLC
Other - Org Name:KATHRYN L D JOHANSEN ARNP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:LEILA DRAKE
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:253-370-2737
Mailing Address - Street 1:12914 86TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5453
Mailing Address - Country:US
Mailing Address - Phone:253-826-0157
Mailing Address - Fax:253-863-9415
Practice Address - Street 1:920 ALDER AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1401
Practice Address - Country:US
Practice Address - Phone:253-826-0157
Practice Address - Fax:253-863-9415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007575363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ75669Medicare UPIN
WA8863658Medicare PIN