Provider Demographics
NPI:1427356781
Name:JOHNSON, TARA
Entity Type:Individual
Prefix:
First Name:TARA
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 1:43335 KALIFORNSKY BEACH RD STE 36
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8280
Mailing Address - Country:US
Mailing Address - Phone:907-262-6331
Mailing Address - Fax:907-260-4892
Practice Address - Street 1:137 FARNSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7601
Practice Address - Country:US
Practice Address - Phone:907-262-0430
Practice Address - Fax:907-262-0431
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
AK1018485171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG675Medicaid
AK1407224793Medicaid
AK1427356781Medicaid