Healthcare Provider Details

I. General information

NPI: 1023454121
Provider Name (Legal Business Name): JANELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 HOSPITAL ROAD
SAINT MARY'S AK
99658-0310
US

IV. Provider business mailing address

870 CHIEF EDDIE HOFFMAN HIGHWAY
BETHEL AK
99559-0528
US

V. Phone/Fax

Practice location:
  • Phone: 907-438-3500
  • Fax: 907-438-3541
Mailing address:
  • Phone: 907-543-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: