Healthcare Provider Details

I. General information

NPI: 1861174476
Provider Name (Legal Business Name): AMANDA MICHELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8836 S VERMONT AVE
LOS ANGELES CA
90044-4832
US

IV. Provider business mailing address

2640 INDUSTRY WAY
LYNWOOD CA
90262-4284
US

V. Phone/Fax

Practice location:
  • Phone: 213-451-4370
  • Fax:
Mailing address:
  • Phone: 310-627-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number851704
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95039305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: