Provider Demographics
NPI:1619726338
Name:JOHNSON, KAYLA BROOKE (LMT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 LEWIS CIR
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862-7154
Mailing Address - Country:US
Mailing Address - Phone:269-783-9230
Mailing Address - Fax:
Practice Address - Street 1:27 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2825
Practice Address - Country:US
Practice Address - Phone:269-783-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61232653225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist