Provider Demographics
NPI:1356819569
Name:JOHNSON, NICOLE HEATHER
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:HEATHER
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 1:4305 OKLAHOMA WAY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-5434
Mailing Address - Country:US
Mailing Address - Phone:818-641-8850
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1160
Practice Address - Country:US
Practice Address - Phone:470-956-8276
Practice Address - Fax:770-795-9161
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA188988363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care