Healthcare Provider Details

I. General information

NPI: 1407984669
Provider Name (Legal Business Name): DIRK A JOHNS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 05/27/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BROOKSIDE DR
LONGMEADOW MA
01106-2318
US

IV. Provider business mailing address

10 BROOKSIDE DR
LONGMEADOW MA
01106-2318
US

V. Phone/Fax

Practice location:
  • Phone: 413-531-7078
  • Fax: 413-531-7078
Mailing address:
  • Phone: 508-795-1555
  • Fax: 508-755-4464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9434
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: