Provider Demographics
NPI:1851496046
Name:JOHNSON, TINA M (FNP)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 COURT SQ
Mailing Address - Street 2:WK STN 20-089
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11120-0001
Mailing Address - Country:US
Mailing Address - Phone:347-957-1252
Mailing Address - Fax:347-396-4360
Practice Address - Street 1:1 COURT SQ
Practice Address - Street 2:WK STN 20-089
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11120-0001
Practice Address - Country:US
Practice Address - Phone:347-957-1252
Practice Address - Fax:347-396-4360
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF334061363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03627929Medicaid