Mallory Johnson, PEDIATRIC NP

Primary specialty

Pediatric Nurse PractitionerTaxonomy code 363LP0200X

License

200850163NP Issued in OR

Practice address

11790 SW Barnes Rd. BLG a
Ste 140
Portland, OR 97225

Phone

(503) 643-2100

Fax

(503) 643-7300

NPI assigned

May 22, 2008

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Mallory Braun Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Nurse Practitioner

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1211414400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1634515200000",
    "number": "1265699508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11790 SW BARNES RD. BLG A",
            "address_2": "STE 140",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "97225",
            "telephone_number": "503-643-2100",
            "fax_number": "503-643-7300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11790 SW BARNES RD. BLG A",
            "address_2": "STE 140",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "97225",
            "telephone_number": "503-643-2100",
            "fax_number": "503-643-7300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "MALLORY",
        "name_prefix": "Ms.",
        "credential": "PEDIATRIC NP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2008-05-22",
        "last_updated": "2021-10-18",
        "certification_date": "2021-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "OR",
            "license": "200850163NP",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MALLORY",
            "last_name": "BRAUN",
            "credential": "PEDIATRIC NURSE PRAC",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Lisa Noel Johnson, M.D.
• Lorenzo Johnson V, BS QMHA
• Lori Johnson
• Lynn Louise Johnson, LPC
• Maggie Johnson, MT-BC
• Marcie Marie Johnson, PAC
• Margaret Lillian Johnson, MSW
• Mariah Johnson, M.D.
• Marie Johnson
• Marisa Protasel Johnson, PMHNP-BC

• Pediatric Nurse Practitioner in Portland, OR
• Providers in Portland, OR by specialty
• Pediatric Nurse Practitioner in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.