Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | ||
N | 156FX1800X | Optician | D2024 | WA |
NPI | 1578650149 |
---|---|
Provider Name | Miss Tibitha Jane Johnston |
First Address | Portland, OR 97233-3710 |
Second Address | Portland, OR 97227-1106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 08/07/2007 |