Provider Demographics
NPI:1033638168
Name:JOHNSON, LAURALIE (ACNP)
Entity Type:Individual
Prefix:
First Name:LAURALIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 FAIR OAKS AVE # 299
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3311
Mailing Address - Country:US
Mailing Address - Phone:858-525-1575
Mailing Address - Fax:
Practice Address - Street 1:710 S CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4613
Practice Address - Country:US
Practice Address - Phone:818-660-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-09
Last Update Date:2017-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007354363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care