Healthcare Provider Details

I. General information

NPI: 1700362720
Provider Name (Legal Business Name): STEPHANIE LYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CROSBY RD STE 1
DOVER NH
03820-4370
US

IV. Provider business mailing address

4 GEORGIANNA WAY
SOUTH BERWICK ME
03908-1771
US

V. Phone/Fax

Practice location:
  • Phone: 603-516-9300
  • Fax:
Mailing address:
  • Phone: 978-490-5548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP221184
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number077584-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: