Provider Demographics
NPI:1407306319
Name:JOHNSON, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
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 1:539 AVIATOR CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1255
Mailing Address - Country:US
Mailing Address - Phone:916-806-7512
Mailing Address - Fax:
Practice Address - Street 1:539 AVIATOR CIR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-1255
Practice Address - Country:US
Practice Address - Phone:916-806-7512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5152346101YM0800X
FLPN5151324164W00000X
FL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide