Healthcare Provider Details

I. General information

NPI: 1902735350
Provider Name (Legal Business Name): AKILAH JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 W VAN BUREN ST APT 2033
AVONDALE AZ
85323-7291
US

IV. Provider business mailing address

11120 W VAN BUREN ST APT 2033
AVONDALE AZ
85323-7291
US

V. Phone/Fax

Practice location:
  • Phone: 602-873-4075
  • Fax:
Mailing address:
  • Phone: 602-873-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberMT-28848
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: