Provider Demographics
NPI:1679906812
Name:JOHNSON, KNICHOLE L (RN)
Entity Type:Individual
Prefix:
First Name:KNICHOLE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GARDEN VILLAGE DR
Mailing Address - Street 2:APT A4
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-3356
Mailing Address - Country:US
Mailing Address - Phone:585-415-7092
Mailing Address - Fax:
Practice Address - Street 1:125 GARDEN VILLAGE DR
Practice Address - Street 2:APT A4
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-3356
Practice Address - Country:US
Practice Address - Phone:585-415-7092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 653445163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse