Healthcare Provider Details

I. General information

NPI: 1912716200
Provider Name (Legal Business Name): LARA CRISTINA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINTS WAY
BERKLEY MA
02779-1343
US

IV. Provider business mailing address

2343 PURCHASE ST
NEW BEDFORD MA
02746-1555
US

V. Phone/Fax

Practice location:
  • Phone: 508-292-1791
  • Fax: 469-746-7555
Mailing address:
  • Phone: 781-436-3352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2279515
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN04545
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN79950
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2279515
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: