Provider Demographics
NPI:1578881603
Name:JOHNSON, NICOLE DEBORAH (CMT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DEBORAH
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 1:1114 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349
Mailing Address - Country:US
Mailing Address - Phone:763-350-6924
Mailing Address - Fax:
Practice Address - Street 1:1114 5TH ST
Practice Address - Street 2:
Practice Address - City:HOWARD LAKE
Practice Address - State:MN
Practice Address - Zip Code:55349
Practice Address - Country:US
Practice Address - Phone:763-350-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist