Provider Demographics
NPI:1053889923
Name:JOHNSON, DYNISHA SHELLETTE
Entity type:Individual
Prefix:
First Name:DYNISHA
Middle Name:SHELLETTE
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 1:631 MAPLE AVE # A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-2211
Mailing Address - Country:US
Mailing Address - Phone:213-637-3002
Mailing Address - Fax:
Practice Address - Street 1:631 MAPLE AVE # A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2211
Practice Address - Country:US
Practice Address - Phone:213-673-3001
Practice Address - Fax:213-626-2458
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker