Provider Demographics
NPI:1073181103
Name:JOHNSON, BILLETTE
Entity Type:Individual
Prefix:
First Name:BILLETTE
Middle Name:
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 1:8802 ROCKAWAY BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8802 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1609
Practice Address - Country:US
Practice Address - Phone:718-634-3461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288188164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty