Provider Demographics
NPI:1336484286
Name:JOHNSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 N MAIN ST
Mailing Address - Street 2:SUITE #105
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1669
Mailing Address - Country:US
Mailing Address - Phone:435-654-1377
Mailing Address - Fax:
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:SUITE #105
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1669
Practice Address - Country:US
Practice Address - Phone:435-654-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF0912023363LF0000X
UT7518925-4405363LF0000X
UT7518925-8900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily