Healthcare Provider Details

I. General information

NPI: 1528828910
Provider Name (Legal Business Name): MARSHA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 E HARDY ST
INGLEWOOD CA
90301-4036
US

IV. Provider business mailing address

4202 W 63RD ST
LOS ANGELES CA
90043-3512
US

V. Phone/Fax

Practice location:
  • Phone: 323-309-9874
  • Fax:
Mailing address:
  • Phone: 323-309-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number595627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: