Provider Demographics
NPI:1578951240
Name:JOHNSON, NICOLE LYNN (CFNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:15476 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-679-3038
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878829163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05855337Medicaid
MS413764YQAHMedicare PIN