Provider Demographics
NPI:1992961254
Name:JOHNSON, NICOLE JANINE
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:JANINE
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 1:1019 PACIFIC AVE
Mailing Address - Street 2:STE. 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4443
Mailing Address - Country:US
Mailing Address - Phone:253-597-4550
Mailing Address - Fax:
Practice Address - Street 1:10510 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5036
Practice Address - Country:US
Practice Address - Phone:253-589-7030
Practice Address - Fax:253-589-7033
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-055020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics