Provider Demographics
NPI:1750388716
Name:JOHNSON, LISA M (MSN, NP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8043 2ND ST
Mailing Address - Street 2:STE 105
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3621
Mailing Address - Country:US
Mailing Address - Phone:562-862-1134
Mailing Address - Fax:562-861-9895
Practice Address - Street 1:8043 2ND ST
Practice Address - Street 2:STE 105
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3621
Practice Address - Country:US
Practice Address - Phone:562-862-1134
Practice Address - Fax:562-861-9895
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP9644363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN4927680Medicaid
CARN4927681Medicaid
CANP9644Medicare ID - Type Unspecified
CARN4927680Medicaid