Provider Demographics
NPI:1932255122
Name:JOHNSON, NICHOLLE LEIGH
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:LEIGH
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 1:715 N BLANDENA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2620
Mailing Address - Country:US
Mailing Address - Phone:503-249-2977
Mailing Address - Fax:
Practice Address - Street 1:7621 N PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-5953
Practice Address - Country:US
Practice Address - Phone:503-240-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion