Provider Demographics
NPI:1891159463
Name:JOHNSON, TIALICKA BURGOS (RNC-OB)
Entity Type:Individual
Prefix:MRS
First Name:TIALICKA
Middle Name:BURGOS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RNC-OB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-5311
Mailing Address - Fax:707-423-4356
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-5311
Practice Address - Fax:707-423-4356
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24176717363LW0102X
VA715790163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health