Healthcare Provider Details

I. General information

NPI: 1497888002
Provider Name (Legal Business Name): SUSAN MARY HART JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HYDE AVE STE 109
VERNON CT
06066-4503
US

IV. Provider business mailing address

30 JORDAN LN
WETHERSFIELD CT
06109-1278
US

V. Phone/Fax

Practice location:
  • Phone: 860-454-0303
  • Fax: 860-875-4242
Mailing address:
  • Phone: 860-263-0253
  • Fax: 860-263-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000687
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: