Provider Demographics
NPI:1215358213
Name:JOHNSON, MIKA LATOY (LPN)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:LATOY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204
Mailing Address - Country:US
Mailing Address - Phone:315-491-6819
Mailing Address - Fax:
Practice Address - Street 1:197 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204
Practice Address - Country:US
Practice Address - Phone:315-491-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280270-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse