Provider Demographics
NPI:1043263452
Name:JOHNSON, WANDA HARRIETTE (NP)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:HARRIETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10700 MACARTHUR BLVD
Practice Address - Street 2:EAST OAKLAND CLINIC, SUITE 14B
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-5260
Practice Address - Country:US
Practice Address - Phone:510-563-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629293956Medicaid
CA1992838437Medicaid