Provider Demographics
NPI:1518744853
Name:JOHNSON, NATALIE
Entity Type:Individual
Prefix:
First Name:NATALIE
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 1:555 E MAIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1876
Mailing Address - Country:US
Mailing Address - Phone:215-954-9440
Mailing Address - Fax:
Practice Address - Street 1:201 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:716-373-4303
Practice Address - Fax:716-373-4327
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY905517163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939Medicaid
NY161039939OtherALL OTHER INSURANCE