Provider Demographics
NPI:1902173628
Name:JOHNSON, BONNIE JEAN
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
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 1:246 KWIGUK STREET
Mailing Address - Street 2:
Mailing Address - City:EMMONAK
Mailing Address - State:AK
Mailing Address - Zip Code:99581-0246
Mailing Address - Country:US
Mailing Address - Phone:907-949-3536
Mailing Address - Fax:907-949-3540
Practice Address - Street 1:246 KWIGUK ST.
Practice Address - Street 2:
Practice Address - City:EMMONAK
Practice Address - State:AK
Practice Address - Zip Code:99581-0246
Practice Address - Country:US
Practice Address - Phone:907-949-3536
Practice Address - Fax:904-949-3540
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-073-DHAT247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other