Healthcare Provider Details

I. General information

NPI: 1629820816
Provider Name (Legal Business Name): OLIVIA ROSE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 08/09/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LATTIMORE RD STE 258
ROCHESTER NY
14620-4155
US

IV. Provider business mailing address

7276 GILLIS RD
VICTOR NY
14564-9541
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-8020
  • Fax:
Mailing address:
  • Phone: 716-785-0659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number744904
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number354978
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: