Basic Information
| Provider Information | |||||||||
| NPI: | 1508824145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLMAN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 W ARBROOK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760143175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172766850 | ||||||||
| FaxNumber: | 8178613023 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W ARBROOK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760143175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172766850 | ||||||||
| FaxNumber: | 8178613023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L8733 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10078811 | 01 | AMERICAID | OTHER | 168202302 | 05 | TX | MEDICAID | 168202304 | 05 | TX | MEDICAID | 19620 | 01 | TX | PARKLAND | OTHER | 0058NS | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 168202309 | 05 | TX | MEDICAID | 159137 | 01 | TX | UNICARE | OTHER | 168202306 | 05 | TX | MEDICAID | 168202303 | 01 | TX | THSTEPS | OTHER | 9075998 | 01 | TX | CIGNA | OTHER | 168202305 | 05 | TX | MEDICAID |