Provider Demographics
NPI:1295052843
Name:JOHNSON, NICHOLE LYNETTE (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:LYNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1700
Mailing Address - Fax:704-316-1701
Practice Address - Street 1:10810 MALLARD CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9786
Practice Address - Country:US
Practice Address - Phone:704-510-8000
Practice Address - Fax:704-510-8006
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCG868AMedicare PIN
NCAC5385578-R641OtherDEA