Provider Demographics
NPI:1821324765
Name:JOHNSON, SAMANTHA JO (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST
Mailing Address - Street 2:SUITE 2050
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2799
Mailing Address - Fax:909-558-2704
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 2050
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2799
Practice Address - Fax:909-558-2704
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2013-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA19464363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics