Provider Demographics
NPI:1013396340
Name:JOHNSON, COULSANDER
Entity Type:Individual
Prefix:
First Name:COULSANDER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4932
Mailing Address - Country:US
Mailing Address - Phone:562-230-3354
Mailing Address - Fax:562-247-1822
Practice Address - Street 1:2090 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-4932
Practice Address - Country:US
Practice Address - Phone:562-230-3354
Practice Address - Fax:562-247-1822
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 374U00000X
CAVN192615164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty