Provider Demographics
NPI:1891576146
Name:JOHNSON, NIYA JOHNIQUE
Entity Type:Individual
Prefix:
First Name:NIYA
Middle Name:JOHNIQUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 N SHADELAND AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-3733
Mailing Address - Country:US
Mailing Address - Phone:317-833-0973
Mailing Address - Fax:
Practice Address - Street 1:4240 N SHADELAND AVE APT 3
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-3733
Practice Address - Country:US
Practice Address - Phone:317-833-0973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23-016381-1376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker