1619246063 NPI number — AMANDA ROXANNE JOHNSON CHA-III

Table of content: AMANDA ROXANNE JOHNSON CHA-III (NPI 1619246063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619246063 NPI number — AMANDA ROXANNE JOHNSON CHA-III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
AMANDA
Provider Middle Name:
ROXANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHA-III
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619246063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 BACK STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHUNGNAK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-437-2138
Provider Business Mailing Address Fax Number:
907-437-2139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMBLER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99786-0110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-445-2129
Provider Business Practice Location Address Fax Number:
907-445-2179
Provider Enumeration Date:
12/14/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172V00000X , with the licence number: 11-1129-II , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)