Provider Demographics
NPI:1972064582
Name:JOHNSON, SANDRA RENEE (MSN, RN, NCSN, PHN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, RN, NCSN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EVERGREEN PUBLIC SCHOOLS
Mailing Address - Street 2:13501 NE 28TH ST.
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-8091
Mailing Address - Country:US
Mailing Address - Phone:360-604-6711
Mailing Address - Fax:
Practice Address - Street 1:EVERGREEN PUBLIC SCHOOLS
Practice Address - Street 2:13501 NE 28TH ST.
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-8091
Practice Address - Country:US
Practice Address - Phone:360-604-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60211079163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1245311141Medicaid