Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 2010030335 | MO |
NPI | 1053617720 |
---|---|
Provider Name | Mrs. Nicole Marie Johnson |
First Address | Kansas City, MO 64108-4619 |
Second Address | Kansas City, MO 64108-4619 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2011 |
Last Update Date | 28/05/2015 |