Provider Demographics
NPI:1609909209
Name:JOHNSON DRIESE, LAURIE LEE (CNM)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:LEE
Last Name:JOHNSON DRIESE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-565-9237
Mailing Address - Fax:360-452-7303
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3909
Practice Address - Country:US
Practice Address - Phone:360-565-0999
Practice Address - Fax:360-452-7303
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60151019367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10019928MOtherOPTIMA
VAC02245OtherMEDICARE PTAN
VA299230OtherANTHEM
VA018695O45Medicare PIN
VA160990920Medicaid
VACN3911OtherRAILROAD MEDICARE PTAN