Provider Demographics
NPI:1871259465
Name:JOHNSON, MAIA LYN (LMT)
Entity type:Individual
Prefix:MS
First Name:MAIA
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 E MOUNTAIN VILLAGE DR STE B
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7332
Mailing Address - Country:US
Mailing Address - Phone:816-500-3680
Mailing Address - Fax:
Practice Address - Street 1:WILD IRIS INTEGRATIVE MASSAGE
Practice Address - Street 2:550 S ALASKA STREET, STE 104 C
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-746-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK181913225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist