Provider Demographics
NPI:1174334080
Name:JOHNSON, LACI NICOLE (APRN, CNM, RDMS)
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN, CNM, RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 PINELAND DR STE 240
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5300
Mailing Address - Country:US
Mailing Address - Phone:214-221-0855
Mailing Address - Fax:214-221-1437
Practice Address - Street 1:5750 PINELAND DR STE 240
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5300
Practice Address - Country:US
Practice Address - Phone:214-221-0855
Practice Address - Fax:214-221-1437
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000446163W00000X, 367A00000X
TX1699482471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography