Provider Demographics
NPI:1356484596
Name:JOHNSTON, NICKLETT R (NP)
Entity Type:Individual
Prefix:
First Name:NICKLETT
Middle Name:R
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 W 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6315
Mailing Address - Country:US
Mailing Address - Phone:520-720-6551
Mailing Address - Fax:520-720-6552
Practice Address - Street 1:688 W 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602
Practice Address - Country:US
Practice Address - Phone:520-720-6551
Practice Address - Fax:520-720-6552
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX546098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184626302Medicaid
TX184626301Medicaid
TX184626303Medicaid
TX8J3774Medicare ID - Type Unspecified
TX184626302Medicaid
TX8J3776Medicare ID - Type Unspecified
TX184626303Medicaid