Provider Demographics
NPI:1962878918
Name:JOHNSON, AMANDA LYNN (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 E EDISON ST
Mailing Address - Street 2:GUESTHOUSE
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3602
Mailing Address - Country:US
Mailing Address - Phone:520-276-5801
Mailing Address - Fax:
Practice Address - Street 1:6085 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2319
Practice Address - Country:US
Practice Address - Phone:520-318-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0985171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist