Provider Demographics
NPI:1811127038
Name:JOHNSON, VIVIAN TINA (RN, NPP)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:TINA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, NPP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:538 ROUTE 25A
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9089
Mailing Address - Country:US
Mailing Address - Phone:631-891-7316
Mailing Address - Fax:631-821-3016
Practice Address - Street 1:538 RT 25A
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9089
Practice Address - Country:US
Practice Address - Phone:631-891-7316
Practice Address - Fax:631-821-3016
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF400187-1101YM0800X
NYF-400187-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health