Healthcare Provider Details

I. General information

NPI: 1952407090
Provider Name (Legal Business Name): CYNTHIA KAYE PHILLIPS-JOHNSON RN, AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3765 E BLUE LUPINE DR STE D
WASILLA AK
99654-8417
US

IV. Provider business mailing address

1399 S TIM AVE
WASILLA AK
99623-9338
US

V. Phone/Fax

Practice location:
  • Phone: 907-707-1671
  • Fax: 907-707-1675
Mailing address:
  • Phone: 385-201-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number224414
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number141780
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017451
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: