Provider Demographics
NPI:1649357351
Name:JOHNSON STEVENSON, LAURA MARIE (BS DC CCEP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:JOHNSON STEVENSON
Suffix:
Gender:F
Credentials:BS DC CCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1850
Mailing Address - Country:US
Mailing Address - Phone:208-324-3730
Mailing Address - Fax:208-324-5512
Practice Address - Street 1:600 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1850
Practice Address - Country:US
Practice Address - Phone:208-324-3730
Practice Address - Fax:208-324-5512
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIRO584111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC5681OtherBLUE CROSS OF IDAHO
ID10019692OtherBLUE SHIELD
IDC5681OtherBLUE CROSS OF IDAHO
ID1649357351Medicare PIN