Provider Demographics
NPI:1154097046
Name:JOHNSON, NICKEY JOE JR (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:NICKEY
Middle Name:JOE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 8TH ST STE 480W
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2403
Mailing Address - Country:US
Mailing Address - Phone:270-762-1547
Mailing Address - Fax:270-752-2854
Practice Address - Street 1:300 S 8TH ST STE 100W
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2446
Practice Address - Country:US
Practice Address - Phone:270-762-1547
Practice Address - Fax:270-752-2854
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016469363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner