Healthcare Provider Details

I. General information

NPI: 1821446477
Provider Name (Legal Business Name): JOHANNA UTTER L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOHANNA UTTER LUSEBRINK

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 E 8TH ST
DAVIS CA
95616-2216
US

IV. Provider business mailing address

622 E 8TH ST
DAVIS CA
95616-2216
US

V. Phone/Fax

Practice location:
  • Phone: 530-757-2064
  • Fax:
Mailing address:
  • Phone: 530-757-2064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC3699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: