Provider Demographics
NPI:1255872719
Name:JOHNSON, SIBONISIWE MOYO (NP)
Entity type:Individual
Prefix:
First Name:SIBONISIWE
Middle Name:MOYO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SIBONISIWE
Other - Middle Name:
Other - Last Name:MOYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:22555 ALESSANDRO BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8533
Mailing Address - Country:US
Mailing Address - Phone:951-656-7081
Mailing Address - Fax:951-656-1710
Practice Address - Street 1:22555 ALESSANDRO BLVD STE B
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-656-7081
Practice Address - Fax:951-656-1710
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005225363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner