Provider Demographics
NPI:1730404245
Name:JOHNSON, NICOLE (LAC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
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:PO BOX 33331
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133
Mailing Address - Country:US
Mailing Address - Phone:206-228-1622
Mailing Address - Fax:
Practice Address - Street 1:340 15TH AVE E
Practice Address - Street 2:STE #203
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5808
Practice Address - Country:US
Practice Address - Phone:206-228-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60134773171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAC60134773OtherWA STATE PROVIDER #