Provider Demographics
NPI:1306072491
Name:JOHNSON, FARLAND IDE (LMT)
Entity type:Individual
Prefix:MS
First Name:FARLAND
Middle Name:IDE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7734 SE 66TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-9658
Mailing Address - Country:US
Mailing Address - Phone:971-404-5634
Mailing Address - Fax:
Practice Address - Street 1:7734 SE 66TH PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-9658
Practice Address - Country:US
Practice Address - Phone:971-404-5634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11138172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker