Basic Information
| Provider Information | |||||||||
| NPI: | 1639348261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LAKESHA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRISTOL | ||||||||
| OtherFirstName: | LAKESHA | ||||||||
| OtherMiddleName: | BENE | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6565 GREEN VALLEY CIR | ||||||||
| Address2: | UNIT 100 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109466187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
| FaxNumber: | 8663401203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA19642 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.