Provider Demographics
NPI:1124715222
Name:JOHNSON, NATHANIEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BATEAU TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-1201
Mailing Address - Country:US
Mailing Address - Phone:585-703-2612
Mailing Address - Fax:
Practice Address - Street 1:2613 W HENRIETTA RD STE F
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2327
Practice Address - Country:US
Practice Address - Phone:585-702-2612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY758875163W00000X
NY404969363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse