Provider Demographics
NPI:1154215010
Name:JOHANSEN, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 262
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4400
Mailing Address - Country:US
Mailing Address - Phone:509-581-6300
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR STE 262
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4400
Practice Address - Country:US
Practice Address - Phone:509-581-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
ID83761566237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist