Provider Demographics
NPI:1962111732
Name:JOHNSON, ALEXIS ROSE ANN
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:ROSE ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:ROSE ANN
Other - Last Name:SHAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5011 SE 30TH AVE APT 77
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-9507
Mailing Address - Country:US
Mailing Address - Phone:760-910-5094
Mailing Address - Fax:
Practice Address - Street 1:3880 SE HARRISON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5899
Practice Address - Country:US
Practice Address - Phone:503-513-4665
Practice Address - Fax:503-513-4663
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24745225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist