Basic Information
| Provider Information | |||||||||
| NPI: | 1285205344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8581 COBALT DR | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130398977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072072372 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7375 OSWEGO RD | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130903717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152910064 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2021 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 347749 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.