Healthcare Provider Details

I. General information

NPI: 1104082346
Provider Name (Legal Business Name): TIESHA D JOHNSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1676 SUNSET AVE
UTICA NY
13502-5416
US

IV. Provider business mailing address

111 HOSPITAL DR ATTN: CREDENTIALING DEPT
UTICA NY
13502
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-4801
  • Fax: 315-624-5401
Mailing address:
  • Phone: 315-801-8534
  • Fax: 315-801-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401131
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.024042
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: