Provider Demographics
NPI:1093218299
Name:JOHNESE, MICA K (WHNP-BC)
Entity type:Individual
Prefix:
First Name:MICA
Middle Name:K
Last Name:JOHNESE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:MICA
Other - Middle Name:
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:565 GRIFFITH DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-0983
Mailing Address - Country:US
Mailing Address - Phone:325-829-1844
Mailing Address - Fax:
Practice Address - Street 1:3737 GOLDMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-2471
Practice Address - Country:US
Practice Address - Phone:214-266-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135787363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health