Healthcare Provider Details

I. General information

NPI: 1407399363
Provider Name (Legal Business Name): LANNETTE DENISE JOHNSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7853 1/2 CRENSHAW BLVD
LOS ANGELES CA
90043-4940
US

IV. Provider business mailing address

7853 1/2 CRENSHAW BLVD
LOS ANGELES CA
90043-4940
US

V. Phone/Fax

Practice location:
  • Phone: 323-747-3490
  • Fax:
Mailing address:
  • Phone: 323-747-3490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95005777
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number652970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: