Provider Demographics
NPI:1639485923
Name:JOHNSON, NICOLE ELISABETH (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELISABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELISABETH
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2820 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5462
Mailing Address - Country:US
Mailing Address - Phone:605-342-9280
Mailing Address - Fax:
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000607363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP000607OtherLICENSE
SDS104894Medicare PIN