Healthcare Provider Details

I. General information

NPI: 1912818139
Provider Name (Legal Business Name): ADAM JOHNSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6062 RADIANCE BLVD E
FIFE WA
98424-3873
US

IV. Provider business mailing address

6062 RADIANCE BLVD E
FIFE WA
98424-3873
US

V. Phone/Fax

Practice location:
  • Phone: 815-501-1558
  • Fax:
Mailing address:
  • Phone: 815-501-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP70158710
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: