Provider Demographics
NPI:1407165368
Name:JOHNSON, NICOLE MARIE (CMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 7TH ST NE
Mailing Address - Street 2:COLUMBIA HEIGHTS
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-2238
Mailing Address - Country:US
Mailing Address - Phone:612-281-8849
Mailing Address - Fax:
Practice Address - Street 1:4541 7TH ST. NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2238
Practice Address - Country:US
Practice Address - Phone:612-281-8849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist