Healthcare Provider Details

I. General information

NPI: 1962111732
Provider Name (Legal Business Name): MS. ALEXIS ROSE ANN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXIS ROSE ANN SHAVER

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 SE HARRISON ST
MILWAUKIE OR
97222-5899
US

IV. Provider business mailing address

5011 SE 30TH AVE APT 77
PORTLAND OR
97202-9507
US

V. Phone/Fax

Practice location:
  • Phone: 503-513-4665
  • Fax: 503-513-4663
Mailing address:
  • Phone: 760-910-5094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24745
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: