Provider Demographics
NPI:1255638730
Name:JOHNSON, NIKKI C (MA CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 POORMAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TWISP
Mailing Address - State:WA
Mailing Address - Zip Code:98856-9743
Mailing Address - Country:US
Mailing Address - Phone:509-997-1440
Mailing Address - Fax:
Practice Address - Street 1:97 POORMAN CREEK RD
Practice Address - Street 2:
Practice Address - City:TWISP
Practice Address - State:WA
Practice Address - Zip Code:98856-9743
Practice Address - Country:US
Practice Address - Phone:509-997-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA436285A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist