Provider Demographics
NPI:1710535687
Name:JOHNSON, MATTISON BROOKE I (LVN)
Entity Type:Individual
Prefix:
First Name:MATTISON
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:I
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 FLETCHER PKWY UNIT 406
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5205
Mailing Address - Country:US
Mailing Address - Phone:209-570-6823
Mailing Address - Fax:
Practice Address - Street 1:8615 FLETCHER PKWY UNIT 406
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5205
Practice Address - Country:US
Practice Address - Phone:209-570-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA696096164X00000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF5653277OtherDRIVER LICENSE