Provider Demographics
NPI:1639348261
Name:JOHNSON, LAKESHA B (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAKESHA
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAKESHA
Other - Middle Name:BENE
Other - Last Name:BRISTOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6565 GREEN VALLEY CIR
Mailing Address - Street 2:UNIT 100
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7036
Mailing Address - Country:US
Mailing Address - Phone:310-946-6187
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:866-340-1203
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant