Healthcare Provider Details

I. General information

NPI: 1063152791
Provider Name (Legal Business Name): DAVID LARS CHRISTIAN JOHNSRUD BA, MAC, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KAREN CHRISTIANE JOHNSRUDE BA, MAC, BSN

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 10/16/2023
Certification Date: 10/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 15TH ST SW MAILSTOP 1002-1-TRI
AUBURN WA
98001-9841
US

IV. Provider business mailing address

3841 N COUNTRY CLUB RD UNIT 2
TUCSON AZ
85716-1011
US

V. Phone/Fax

Practice location:
  • Phone: 520-225-9785
  • Fax:
Mailing address:
  • Phone: 520-225-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number60607354
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRNP289863
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: