Provider Demographics
NPI:1124634233
Name:JOHNSON, MACKENA ELSIE
Entity type:Individual
Prefix:
First Name:MACKENA
Middle Name:ELSIE
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 1:17031 VANOVER CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8130
Mailing Address - Country:US
Mailing Address - Phone:907-980-1812
Mailing Address - Fax:
Practice Address - Street 1:SPORTS & SPINAL INJURY CLINIC
Practice Address - Street 2:6634 LAKE OTIS PKWY #A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507
Practice Address - Country:US
Practice Address - Phone:907-522-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK160645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist