Healthcare Provider Details

I. General information

NPI: 1821920034
Provider Name (Legal Business Name): THERESA DIANE JOHNSON BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19200 N KELSEY ST
MONROE WA
98272-1431
US

IV. Provider business mailing address

19200 N KELSEY ST
MONROE WA
98272-1431
US

V. Phone/Fax

Practice location:
  • Phone: 360-794-7994
  • Fax: 360-805-4761
Mailing address:
  • Phone: 360-794-7994
  • Fax: 360-805-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60618683
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: