Provider Demographics
NPI:1124244298
Name:JOHNSON, LYUDMILA G (LMP)
Entity type:Individual
Prefix:
First Name:LYUDMILA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LYUDMILA
Other - Middle Name:G
Other - Last Name:PETROVSKAYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:2607 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE 2H1
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4700
Mailing Address - Country:US
Mailing Address - Phone:253-460-1824
Mailing Address - Fax:253-460-1920
Practice Address - Street 1:2607 BRIDGEPORT WAY W
Practice Address - Street 2:2H1
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4700
Practice Address - Country:US
Practice Address - Phone:253-460-1824
Practice Address - Fax:253-460-1920
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022715174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist