Provider Demographics
NPI:1821446477
Name:UTTER, JOHANNA (LAC)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:UTTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:UTTER
Other - Last Name:LUSEBRINK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:622 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2216
Mailing Address - Country:US
Mailing Address - Phone:530-757-2064
Mailing Address - Fax:
Practice Address - Street 1:622 E 8TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2216
Practice Address - Country:US
Practice Address - Phone:530-757-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3699171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist