Provider Demographics
NPI:1639663248
Name:JOHAL, AMANDEEP KAUR (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDEEP
Middle Name:KAUR
Last Name:JOHAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:AMANDEEP
Other - Middle Name:KAUR
Other - Last Name:UPPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-9093
Practice Address - Street 1:1140 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009408363LF0000X
CA95063589163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice