Provider Demographics
NPI:1902540412
Name:JOHNSON, PORSCHE NICOLE
Entity Type:Individual
Prefix:
First Name:PORSCHE
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PORSCHE
Other - Middle Name:NICOLE
Other - Last Name:BLUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 GALLOWAY ST
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-3909
Mailing Address - Country:US
Mailing Address - Phone:253-983-2519
Mailing Address - Fax:253-583-8478
Practice Address - Street 1:1201 GALLOWAY ST
Practice Address - Street 2:
Practice Address - City:STEILACOOM
Practice Address - State:WA
Practice Address - Zip Code:98388-3909
Practice Address - Country:US
Practice Address - Phone:253-983-2519
Practice Address - Fax:253-583-8478
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASP612319772355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant