Provider Demographics
NPI:1275212979
Name:JOHNSON, NICHOLE LASHAWN
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LASHAWN
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 1:1319 PATRIOT LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1871
Mailing Address - Country:US
Mailing Address - Phone:240-695-6494
Mailing Address - Fax:
Practice Address - Street 1:1319 PATRIOT LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1871
Practice Address - Country:US
Practice Address - Phone:240-695-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator