Provider Demographics
NPI:1104142884
Name:JOHNSON, LORI KATHLEEN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:KATHLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36937 MEADOW BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8000
Mailing Address - Country:US
Mailing Address - Phone:951-769-4341
Mailing Address - Fax:
Practice Address - Street 1:36937 MEADOW BROOK WAY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-8000
Practice Address - Country:US
Practice Address - Phone:951-769-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA542481163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse