Provider Demographics
NPI:1336457613
Name:JOHNSON, NICOLE LEANN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 ODELL LN
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-7802
Mailing Address - Country:US
Mailing Address - Phone:479-462-5915
Mailing Address - Fax:479-430-7458
Practice Address - Street 1:2102 ODELL LN
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-7802
Practice Address - Country:US
Practice Address - Phone:479-462-5915
Practice Address - Fax:479-430-7458
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7036225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist