Provider Demographics
NPI:1144592643
Name:JOHNSON, ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
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 1:508 GIBSON DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 GIBSON DR
Practice Address - Street 2:SUITE 220
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5794
Practice Address - Country:US
Practice Address - Phone:916-773-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA705301363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics