Provider Demographics
NPI:1649092701
Name:JOHNSON, PRISCILLA (NBC-HWC)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 HARBOR BLVD APT 106
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-6258
Mailing Address - Country:US
Mailing Address - Phone:949-942-5410
Mailing Address - Fax:
Practice Address - Street 1:2350 HARBOR BLVD APT 106
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6258
Practice Address - Country:US
Practice Address - Phone:949-942-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-3826544171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach