Provider Demographics
NPI:1326102500
Name:JOHNSON, ALICE (FNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NORTH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1561
Mailing Address - Country:US
Mailing Address - Phone:315-787-5100
Mailing Address - Fax:315-787-5108
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5100
Practice Address - Fax:315-787-5108
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330480363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00003445OtherR.R. MEDICARE
NY01235432Medicaid
NY109570BJOtherPREFERRED CARE
NYP019330480OtherBLUE CHOICE
NYP019330480OtherBLUE CHOICE
NY109570BJOtherPREFERRED CARE