Provider Demographics
NPI:1124351929
Name:BRANCH, JOHNNIE LEE
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:LEE
Last Name:BRANCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-779-7900
Mailing Address - Fax:
Practice Address - Street 1:6154 MISSION GORGE RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3435
Practice Address - Country:US
Practice Address - Phone:619-285-1718
Practice Address - Fax:619-285-3803
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator