MEDICARE: NICOLE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	009365	NY
2	224Z00000X	Occupational Therapy Assistant	OTA15677	FL

General Provider Information

NPI Number	:	1922512078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JOHNSON

Provider Business Mailing Address
First Line	:	1498 PORT MALABAR BLVD NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-5240
Country	:	US
Telephone Number	:	321-848-7349
Fax Number	:

Provider Business Practice Location Address
First Line	:	1498 PORT MALABAR BLVD NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-5240
Country	:	US
Telephone Number	:	321-848-7349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2017
Last Update Date	:	11/28/2017

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Directions to “ NICOLE JOHNSON ” Practice Location

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