Basic Information
| Provider Information | |||||||||
| NPI: | 1003897745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ORONDO AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | 5096644590 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 ORONDO AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | 5096644588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AP30003181 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | RN00066360 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | AP30003181 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9608605 | 05 | WA | MEDICAID |