Provider Demographics
NPI:1396893483
Name:JOHNSON, BROOKE ELIZABETH (LMP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
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:PO BOX 1937
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-1937
Mailing Address - Country:US
Mailing Address - Phone:253-722-3162
Mailing Address - Fax:
Practice Address - Street 1:34321 32 AVE E
Practice Address - Street 2:
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328
Practice Address - Country:US
Practice Address - Phone:253-722-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008012174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist