Healthcare Provider Details

I. General information

NPI: 1396831665
Provider Name (Legal Business Name): JOHANNA LYNN OLSON-KENNEDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FAIR OAKS AVE STE 105
PASADENA CA
91105-2536
US

IV. Provider business mailing address

301 S FAIR OAKS AVE STE 105
PASADENA CA
91105-2536
US

V. Phone/Fax

Practice location:
  • Phone: 866-846-5062
  • Fax:
Mailing address:
  • Phone: 866-846-5062
  • Fax: 800-890-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA067352
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA67352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: