Healthcare Provider Details

I. General information

NPI: 1285205344
Provider Name (Legal Business Name): NICOLE LEE JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7375 OSWEGO RD
LIVERPOOL NY
13090-3717
US

IV. Provider business mailing address

8581 COBALT DR
CICERO NY
13039-8977
US

V. Phone/Fax

Practice location:
  • Phone: 315-291-0064
  • Fax:
Mailing address:
  • Phone: 607-207-2372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347749
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: