Provider Demographics
NPI:1861102873
Name:JOHNSON, KORTNIE (SDH)
Entity type:Individual
Prefix:
First Name:KORTNIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17030 SW ROCKY RAMBLE LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9215
Mailing Address - Country:US
Mailing Address - Phone:503-928-0445
Mailing Address - Fax:
Practice Address - Street 1:17030 SW ROCKY RAMBLE LN
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9215
Practice Address - Country:US
Practice Address - Phone:503-928-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No124Q00000XDental ProvidersDental Hygienist