Provider Demographics
NPI:1235843533
Name:JOHNSON, VICKIE LAVON
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LAVON
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 1:32 HERKIMER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2766
Mailing Address - Country:US
Mailing Address - Phone:718-670-4416
Mailing Address - Fax:
Practice Address - Street 1:4500 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2205
Practice Address - Country:US
Practice Address - Phone:718-670-4416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist