1831825686 NPI number — MARY ELLEN JOHNSON FNP-BC

Table of content: MARY ELLEN JOHNSON FNP-BC (NPI 1831825686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831825686 NPI number — MARY ELLEN JOHNSON FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PASSINEAU
Provider Other First Name:
MARY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831825686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHENECTADY RD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-782-3700
Provider Business Mailing Address Fax Number:
518-782-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1783 ROUTE 9 STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALFMOON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-383-4198
Provider Business Practice Location Address Fax Number:
518-383-0448
Provider Enumeration Date:
07/25/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  349935 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)