Provider Demographics
NPI:1477214351
Name:JOHNSON, NICOLE THERESA (CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERESA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-5904
Mailing Address - Country:US
Mailing Address - Phone:605-351-4207
Mailing Address - Fax:
Practice Address - Street 1:1417 S CLIFF AVE STE 400A
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1064
Practice Address - Country:US
Practice Address - Phone:605-322-8946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCM000094176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife