Healthcare Provider Details

I. General information

NPI: 1235929563
Provider Name (Legal Business Name): MS NICKYS BODY SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1593 US HIGHWAY 22 STE 125
WATCHUNG NJ
07069-6507
US

IV. Provider business mailing address

514 LOCUST ST
ROSELLE NJ
07203-1146
US

V. Phone/Fax

Practice location:
  • Phone: 858-356-4259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE JOHNSON
Title or Position: OWNER/PRACTIONER
Credential:
Phone: 702-268-6488