Provider Demographics
NPI:1902101595
Name:JOHNSON, CAROLE LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PARK TER E APT 2L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1521
Mailing Address - Country:US
Mailing Address - Phone:212-567-2547
Mailing Address - Fax:
Practice Address - Street 1:2735 HENRY HUDSON PKWY W
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4701
Practice Address - Country:US
Practice Address - Phone:718-884-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002022-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist