Provider Demographics
NPI:1326630559
Name:FARUQ, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:FARUQ
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 1:1809 BAYWOOD DR APT 202
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3350
Mailing Address - Country:US
Mailing Address - Phone:951-867-1198
Mailing Address - Fax:
Practice Address - Street 1:10351 SANTA MONICA BLVD
Practice Address - Street 2:UNIT 100 STUDIO 19
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4036
Practice Address - Country:US
Practice Address - Phone:951-867-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty