Provider Demographics
NPI:1013579317
Name:JOHNSON, CAMILLE MACHEA
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MACHEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 S TIMBERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8937
Mailing Address - Country:US
Mailing Address - Phone:907-230-8191
Mailing Address - Fax:
Practice Address - Street 1:2521 E MOUNTAIN VILLAGE DR STE F
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7373
Practice Address - Country:US
Practice Address - Phone:907-290-3760
Practice Address - Fax:907-631-0647
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNURR37059163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)