Provider Demographics
NPI:1326554395
Name:JOHNSON, NICHELLE
Entity Type:Individual
Prefix:
First Name:NICHELLE
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 1:5502 CANYON BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-2090
Mailing Address - Country:US
Mailing Address - Phone:832-640-0079
Mailing Address - Fax:281-595-7621
Practice Address - Street 1:5502 CANYON BLUFF CT
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-2090
Practice Address - Country:US
Practice Address - Phone:832-640-0079
Practice Address - Fax:281-595-7621
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246RP1900X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy