Provider Demographics
NPI:1164267308
Name:JOHNSON, HEATHER (LPN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:HAIRSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:17404 44TH AVE E APT Q106
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-5925
Mailing Address - Country:US
Mailing Address - Phone:951-412-8982
Mailing Address - Fax:
Practice Address - Street 1:17404 44TH AVE E APT Q106
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98446-5925
Practice Address - Country:US
Practice Address - Phone:951-412-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61517186164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse