MEDICARE: CARLA JOHNSON LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00023300	WA

General Provider Information

NPI Number	:	1912187378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA JOHNSON LMP

Provider Business Mailing Address
First Line	:	2106 W CLEARVIEW DR
Second Line	:
City	:	ELLENSBURG
State	:	WA
Zip	:	98926-2331
Country	:	US
Telephone Number	:	509-899-1959
Fax Number	:	509-933-3658

Provider Business Practice Location Address
First Line	:	1206 N DOLARWAY RD
Second Line	:	SUITE # 211
City	:	ELLENSBURG
State	:	WA
Zip	:	98926-8392
Country	:	US
Telephone Number	:	509-925-6869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	07/05/2011

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