Healthcare Provider Details

I. General information

NPI: 1982070728
Provider Name (Legal Business Name): MRS. NICOLA M JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ASHFORD ST
BROOKLYN NY
11207-3204
US

IV. Provider business mailing address

300 ASHFORD ST
BROOKLYN NY
11207-3204
US

V. Phone/Fax

Practice location:
  • Phone: 718-235-3478
  • Fax:
Mailing address:
  • Phone: 718-235-3478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: