Provider Demographics
NPI:1982070728
Name:JOHNSON, NICOLA M
Entity Type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:M
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 1:300 ASHFORD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-3204
Mailing Address - Country:US
Mailing Address - Phone:718-235-3478
Mailing Address - Fax:
Practice Address - Street 1:300 ASHFORD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3204
Practice Address - Country:US
Practice Address - Phone:718-235-3478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X
NY133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No132700000XDietary & Nutritional Service ProvidersDietary Manager