Provider Demographics
NPI:1396012894
Name:JOHNSON, FELICIA WAMBE (LPN)
Entity Type:Individual
Prefix:MS
First Name:FELICIA
Middle Name:WAMBE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 HECKSCHER AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2120
Mailing Address - Country:US
Mailing Address - Phone:631-357-9866
Mailing Address - Fax:
Practice Address - Street 1:1735 HECKSCHER AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2120
Practice Address - Country:US
Practice Address - Phone:631-357-9866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199163-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse