Provider Demographics
NPI:1639446115
Name:JOHNSON, KORI A (CHP)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CASANOFF WAY
Mailing Address - Street 2:
Mailing Address - City:KIANA
Mailing Address - State:AK
Mailing Address - Zip Code:99749
Mailing Address - Country:US
Mailing Address - Phone:907-475-2199
Mailing Address - Fax:907-475-2198
Practice Address - Street 1:130 CASANOFF WAY
Practice Address - Street 2:
Practice Address - City:KIANA
Practice Address - State:AK
Practice Address - Zip Code:99749
Practice Address - Country:US
Practice Address - Phone:907-475-2199
Practice Address - Fax:907-475-2198
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1112-II172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker