Healthcare Provider Details

I. General information

NPI: 1275093460
Provider Name (Legal Business Name): MABEL YATTA JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 BRIDGE ST # 215
LOWELL MA
01852-1270
US

IV. Provider business mailing address

24 OAK AVE
TYNGSBORO MA
01879-1779
US

V. Phone/Fax

Practice location:
  • Phone: 978-459-2306
  • Fax: 978-453-9394
Mailing address:
  • Phone: 978-995-2533
  • Fax: 888-340-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number265003
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: