Healthcare Provider Details

I. General information

NPI: 1740684901
Provider Name (Legal Business Name): CHARYSSE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARYSSE BROWN PA

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 BOULEVARD
WEST HARTFORD CT
06119-1801
US

IV. Provider business mailing address

18 TOWNLEY ST APT H3
HARTFORD CT
06105-1864
US

V. Phone/Fax

Practice location:
  • Phone: 860-986-6440
  • Fax:
Mailing address:
  • Phone: 917-302-5899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3209
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: