Provider Demographics
NPI:1588951883
Name:JOHNSON, ALTIA N (R N)
Entity type:Individual
Prefix:
First Name:ALTIA
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:R N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6216
Mailing Address - Country:US
Mailing Address - Phone:209-381-1110
Mailing Address - Fax:209-381-1102
Practice Address - Street 1:260 E 15TH STREET
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341
Practice Address - Country:US
Practice Address - Phone:209-381-1110
Practice Address - Fax:209-381-1102
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425172163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA946000521Medicaid