Healthcare Provider Details

I. General information

NPI: 1356484596
Provider Name (Legal Business Name): NICKLETT R JOHNSTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 W 4TH ST STE B
BENSON AZ
85602
US

IV. Provider business mailing address

688 W 4TH ST STE B
BENSON AZ
85602-6315
US

V. Phone/Fax

Practice location:
  • Phone: 520-720-6551
  • Fax: 520-720-6552
Mailing address:
  • Phone: 520-720-6551
  • Fax: 520-720-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number546098
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: