Provider Demographics
NPI:1932180767
Name:JOHNSON, CAROLE ANN (MA CCCA)
Entity Type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCCA
Other - Prefix:MS
Other - First Name:CAROLE
Other - Middle Name:ANN
Other - Last Name:FORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCCA
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00003723231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7076896Medicaid
WA000350650Medicare ID - Type UnspecifiedCLINIC NUMBER