Basic Information
| Provider Information | |||||||||
| NPI: | 1710207634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | BLDG 7503 | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195244068 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | BLDG 7503 | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195244068 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45635 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | DR.0054891 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 45635 | 01 | AZ | STATE MEDICAL LICENSE | OTHER | 55533345 | 05 | CO | MEDICAID |