Healthcare Provider Details

I. General information

NPI: 1760908396
Provider Name (Legal Business Name): MISS EMILY NICOLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY NICOLE EDWARDS

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5209
US

IV. Provider business mailing address

4130 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5209
US

V. Phone/Fax

Practice location:
  • Phone: 405-267-3246
  • Fax: 405-267-3290
Mailing address:
  • Phone: 405-267-3246
  • Fax: 405-267-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: