Provider Demographics
NPI:1891107439
Name:JOHNSON, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 LYNDON ST APT 17
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3740
Mailing Address - Country:US
Mailing Address - Phone:510-725-9949
Mailing Address - Fax:
Practice Address - Street 1:1221 LYNDON ST APT 17
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3740
Practice Address - Country:US
Practice Address - Phone:510-725-9949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program