Provider Demographics
NPI:1063380590
Name:JOHNSON, KHADIJAH
Entity type:Individual
Prefix:
First Name:KHADIJAH
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 1:1315 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6701
Mailing Address - Country:US
Mailing Address - Phone:907-231-1597
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7426
Practice Address - Country:US
Practice Address - Phone:907-474-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker