Healthcare Provider Details

I. General information

NPI: 1053118950
Provider Name (Legal Business Name): JOHNNY IV FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 ELECTRIC AVE STE 102
FITCHBURG MA
01420-7954
US

IV. Provider business mailing address

33 ELECTRIC AVE STE 102
FITCHBURG MA
01420-7954
US

V. Phone/Fax

Practice location:
  • Phone: 978-343-7246
  • Fax: 978-343-7247
Mailing address:
  • Phone: 978-343-7246
  • Fax: 978-343-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2351241
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: