Provider Demographics
NPI:1457096885
Name:JOHNSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:1361 S GREENFIELD RD APT 1059
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3391
Mailing Address - Country:US
Mailing Address - Phone:719-321-5099
Mailing Address - Fax:
Practice Address - Street 1:4225 E UNIVERSITY DR APT 128
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7092
Practice Address - Country:US
Practice Address - Phone:719-321-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLIC23-07617372600000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion