Provider Demographics
NPI:1407399363
Name:JOHNSON, LANNETTE DENISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LANNETTE
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7853 1/2 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-4940
Mailing Address - Country:US
Mailing Address - Phone:323-747-3490
Mailing Address - Fax:
Practice Address - Street 1:7853 1/2 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-4940
Practice Address - Country:US
Practice Address - Phone:323-747-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA652970163W00000X
CA95005777363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse