Provider Demographics
NPI:1568556660
Name:JOHANSEN, ANDREA (DOM)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 TRINITY DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-663-1339
Mailing Address - Fax:505-662-7371
Practice Address - Street 1:2610 TRINITY DR
Practice Address - Street 2:SUITE 14
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-663-1339
Practice Address - Fax:505-662-7371
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM534171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist