Provider Demographics
NPI:1659664571
Name:JOHNSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:P
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-0297
Mailing Address - Country:US
Mailing Address - Phone:716-984-1296
Mailing Address - Fax:
Practice Address - Street 1:160 WALLACE WAY BLDG 9
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624
Practice Address - Country:US
Practice Address - Phone:585-617-2314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005855235Z00000X
NY022791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist