Provider Demographics
NPI:1841442282
Name:JOHNSON, TRICIA ANTOINETTE
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:ANTOINETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 S 6TH AVE
Mailing Address - Street 2:PRIVATE HOUSE
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4410
Mailing Address - Country:US
Mailing Address - Phone:914-665-0184
Mailing Address - Fax:
Practice Address - Street 1:534 S 6TH AVE
Practice Address - Street 2:PRIVATE HOUSE
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4410
Practice Address - Country:US
Practice Address - Phone:914-665-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294913-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse