Basic Information
| Provider Information | |||||||||
| NPI: | 1750388716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.S.N., NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8043 2ND ST | ||||||||
| Address2: | STE 105 | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902413621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628621134 | ||||||||
| FaxNumber: | 5628619895 | ||||||||
| Practice Location | |||||||||
| Address1: | 8043 2ND ST | ||||||||
| Address2: | STE 105 | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902413621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628621134 | ||||||||
| FaxNumber: | 5628619895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP9644 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | RN4927680 | 05 | CA | MEDICAID | RN4927681 | 05 | CA | MEDICAID |