Basic Information
Provider Information
NPI: 1003003138
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSON-FENTER
FirstName: TRICIA
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: LMP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 946
Address2:  
City: SNOHOMISH
State: WA
PostalCode: 982910946
CountryCode: US
TelephoneNumber: 3605630629
FaxNumber:  
Practice Location
Address1: 119 UNION AVE
Address2: SUITE B
City: SNOHOMISH
State: WA
PostalCode: 982902942
CountryCode: US
TelephoneNumber: 3605630629
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/02/2007
LastUpdateDate: 10/02/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA00024629WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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