Provider Demographics
NPI:1639908882
Name:JOHNSON, NICOLE NYESHA (LPN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:NYESHA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S 57TH ST # A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1928
Mailing Address - Country:US
Mailing Address - Phone:215-617-5996
Mailing Address - Fax:
Practice Address - Street 1:514 S 57TH ST # A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1928
Practice Address - Country:US
Practice Address - Phone:215-617-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN295419167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician