Provider Demographics
NPI:1205933090
Name:JOHNSTON, NICOLINA M (PT)
Entity type:Individual
Prefix:
First Name:NICOLINA
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 COURTNEY DR
Mailing Address - Street 2:SEDGLEY OFFICE PARK
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2696
Mailing Address - Country:US
Mailing Address - Phone:304-720-5433
Mailing Address - Fax:304-720-5436
Practice Address - Street 1:6 COURTNEY DR
Practice Address - Street 2:SEDGLEY OFFICE PARK
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2696
Practice Address - Country:US
Practice Address - Phone:304-720-5433
Practice Address - Fax:304-720-5436
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004820Medicaid
WV4132661Medicare ID - Type Unspecified