Healthcare Provider Details

I. General information

NPI: 1700461811
Provider Name (Legal Business Name): HEATHER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6044 LAKESHORE RD
CICERO NY
13039-8851
US

IV. Provider business mailing address

6044 LAKESHORE RD
CICERO NY
13039-8851
US

V. Phone/Fax

Practice location:
  • Phone: 315-264-5273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: