Basic Information
| Provider Information | |||||||||
| NPI: | 1639799836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LASHAUN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 892 27TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921541444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195754687 | ||||||||
| FaxNumber: | 6195751215 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 MORENA BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
| FaxNumber: | 6192755069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2020 | ||||||||
| LastUpdateDate: | 04/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 274668 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.