Provider Demographics
NPI:1265565311
Name:JOHNSON, EVELYN
Entity type:Individual
Prefix:MRS
First Name:EVELYN
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 1:4016 SPRUCE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1112
Mailing Address - Country:US
Mailing Address - Phone:907-456-4524
Mailing Address - Fax:907-456-5524
Practice Address - Street 1:542 4TH AVE
Practice Address - Street 2:STE. 234
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4714
Practice Address - Country:US
Practice Address - Phone:907-456-4524
Practice Address - Fax:907-456-5524
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK272340171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM4322Medicaid