Healthcare Provider Details

I. General information

NPI: 1336649771
Provider Name (Legal Business Name): BRIANNA NICOLE JOHNSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

8008 3RD AVE
BROOKLYN NY
11209-3862
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6000
  • Fax:
Mailing address:
  • Phone: 718-833-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number311696
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: