Provider Demographics
NPI:1780903310
Name:JOHNSON, HEATHER M (LPN)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:M
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 1:12 RHOADS DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6306
Mailing Address - Country:US
Mailing Address - Phone:315-798-4350
Mailing Address - Fax:315-798-4352
Practice Address - Street 1:12 RHOADS DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6306
Practice Address - Country:US
Practice Address - Phone:315-798-4350
Practice Address - Fax:315-798-4352
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258170-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse