Healthcare Provider Details

I. General information

NPI: 1003244922
Provider Name (Legal Business Name): NANCY JOHNSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 ROXBURY ST APT 1C
STATEN ISLAND NY
10303-1915
US

IV. Provider business mailing address

80 ROXBURY ST APT 1C
STATEN ISLAND NY
10303-1915
US

V. Phone/Fax

Practice location:
  • Phone: 347-938-0884
  • Fax:
Mailing address:
  • Phone: 718-600-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number235365-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number695149
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: