Provider Demographics
NPI:1821972373
Name:JOHNSON, NICOLE MARIE (CPS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2591
Mailing Address - Country:US
Mailing Address - Phone:206-329-6485
Mailing Address - Fax:
Practice Address - Street 1:2212 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2591
Practice Address - Country:US
Practice Address - Phone:206-329-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty