Healthcare Provider Details

I. General information

NPI: 1477065183
Provider Name (Legal Business Name): BETHEL ALVARO JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 N LA BREA AVE
LOS ANGELES CA
90028-7505
US

IV. Provider business mailing address

PO BOX 931629
LOA ANGELES CA
90093
US

V. Phone/Fax

Practice location:
  • Phone: 323-798-5158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: