=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841596525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANNE JOHNSON LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2011
-----------------------------------------------------
Last Update Date | 01/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6834 S CLEMENT AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-414-7214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6834 S CLEMENT AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-414-7214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA 60204589
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------