Provider Demographics
NPI:1164835369
Name:JOHNSON, NICOLA
Entity Type:Individual
Prefix:MISS
First Name:NICOLA
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 1:4516 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3007
Mailing Address - Country:US
Mailing Address - Phone:347-409-7175
Mailing Address - Fax:
Practice Address - Street 1:4516 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3007
Practice Address - Country:US
Practice Address - Phone:347-409-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318507164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse