Provider Demographics
NPI:1538757133
Name:JOHNSON, NACOLE (RN)
Entity type:Individual
Prefix:
First Name:NACOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 N ROOSEVELT DR APT 104
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7053
Mailing Address - Country:US
Mailing Address - Phone:503-717-7150
Mailing Address - Fax:
Practice Address - Street 1:1150 N ROOSEVELT DR APT 104
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7053
Practice Address - Country:US
Practice Address - Phone:503-717-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201406840RN163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management