MEDICARE: LANNETTE DENISE JOHNSON NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	652970	CA
2	363LA2100X	Acute Care Nurse Practitioner	95005777	CA

General Provider Information

NPI Number	:	1407399363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANNETTE DENISE JOHNSON NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	7853 1/2 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-4940
Country	:	US
Telephone Number	:	323-747-3490
Fax Number	:

Provider Business Practice Location Address
First Line	:	7853 1/2 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-4940
Country	:	US
Telephone Number	:	323-747-3490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2016
Last Update Date	:	12/29/2016

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