Provider Demographics
NPI:1891856993
Name:JOHNSON, PATTY JO (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PATTY
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1051 E 4TH ST
Mailing Address - Street 2:51-1N
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2548
Mailing Address - Country:US
Mailing Address - Phone:909-988-7699
Mailing Address - Fax:909-758-5686
Practice Address - Street 1:8608 UTICA AVE
Practice Address - Street 2:209
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4877
Practice Address - Country:US
Practice Address - Phone:909-989-3223
Practice Address - Fax:909-758-5686
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8096171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist