Provider Demographics
NPI:1730910332
Name:JOHNSON, KORESHA B
Entity type:Individual
Prefix:
First Name:KORESHA
Middle Name:B
Last Name:JOHNSON
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 1:521 S HIDALGO AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4047
Mailing Address - Country:US
Mailing Address - Phone:323-215-5843
Mailing Address - Fax:
Practice Address - Street 1:691 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-5003
Practice Address - Country:US
Practice Address - Phone:626-698-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker