Provider Demographics
NPI:1841522604
Name:JOHNSON, NICOLE MARTRICE (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARTRICE
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 1:149 LIND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903
Mailing Address - Country:US
Mailing Address - Phone:419-961-5425
Mailing Address - Fax:
Practice Address - Street 1:149 LIND AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2103
Practice Address - Country:US
Practice Address - Phone:419-961-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126342164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse