Provider Demographics
NPI:1033531595
Name:JOHNSON, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12802 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1607
Mailing Address - Country:US
Mailing Address - Phone:347-306-5064
Mailing Address - Fax:347-905-4509
Practice Address - Street 1:128 02 111 TH AVENUE
Practice Address - Street 2:
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:347-306-5064
Practice Address - Fax:347-905-4507
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345587363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily