Provider Demographics
NPI:1841952124
Name:JOHNSON, NIKIA NICOLE
Entity type:Individual
Prefix:MISS
First Name:NIKIA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 BARIAL AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-3405
Mailing Address - Country:US
Mailing Address - Phone:251-648-5727
Mailing Address - Fax:228-471-5182
Practice Address - Street 1:2103 BARIAL AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3405
Practice Address - Country:US
Practice Address - Phone:251-648-5727
Practice Address - Fax:228-471-5182
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6475605347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6475605OtherDL